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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C.

(02)408-7738/0921-3278041

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TABLE OF CONTENTS I. Psychiatric Nursing, 3 II. Basic Principles of Psychiatric Nursing, 3 III.3 Levels of Psychiatric Nursing (Levels of Health), 3 a. Primary, 3 b. Secondary, 4 c. Tertiary, 6 IV. Criteria of Mental Health, 6 V. Components of Assessment of Mental Status, 6 VI. DSM V (Diagnostic and Statistical Manual for Mental Health, 7 VII. Conceptual Models of Psychiatric Treatment, 7 VIII. Psychosocial Theory of Eric Erikson, 7 IX. Psychosexual (Psychoanalytical) Theory of Sigmund Freud, 7 a. Freudian Theory Component, 8 X. Essential Elements of Nurse-Client Contact, 9 XI. Four Phases of Nurse-Client Contact, 10 a. Pre-interaction/Pre-orientation, 10 b. Orientation, 10 c. Working Phase,11 d. Termination, 11 XII. Therapeutic Communication, 11 a. Therapeutic Communication Techniques, 11 b. Blocks to Therapeutic Communication, 12 XIII. Behavioral Therapy, 13 A. Terminologies, 13 a. Classical Conditioning, 13 b. Operant Conditioning, 14 c. Behavioral Treatments, 16 XIV. Group Therapy, 16 A. Definition, 16 B. Types of Groups, 16 C. Advantage of Group Therapy, 17 D. Principles of Group Therapy, 17 E. Phases of Group Therapy, 17
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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XV. Defense Mechanisms, 18 XVI. Anxiety, 20 A. Definition, 20 B. Major Assessment criterion for Measuring Degree of Anxiety, 20 C. Potential Nursing Diagnosis, 21 D. Nursing Intervention, 21 XVII. Types of Anxiety Disorder, 22 A. Phobia and Panic Disorder, 22 B. Obsessive-Compulsive Disorder, 22 C. Post Traumatic Stress Disorder, 23 D. Anxiolytic/Anti-Anxiety Drugs, 24 a. Benzodiazepine, 24 b. Barbiturates, 24 c. Atypical Anxiolytics, 25 XVIII. Psychotic Disorder: Schizophrenia, 25 A. Assessment Finding: General Signs, 25 B. Prioritized Nursing Diagnoses for all types of Schizophrenia, 27 C. Five Types of Schizophrenia, 27 D. Principle of Care in Schizophrenia, 28 XIX. Antipsychotics, 28 A. Phenothiazine, 28 B. Butyrophenones, 29 C. Thioxanthenes, 29 D. Atypical Anxiolytics, 29 E. Six Common Anticholinergic Side Effects of Antipsychotics, 29 F. Acute/Common side Effect for Prolonged use of Antipsychotics,30 G. Anti-Extrapyramidal Medications, 31 H. Adverse Effects of Antipsychotic Drugs, 31 XX. Affective/ Mood Disorder, 31 A. Types I. Depressive Disorder, 31 a Antidepressants/ Thymoleptics, 34 i. Selective Serotonin Reuptake Inhibitors (SSRI), 34 ii. 2nd Generation Tricyclic Antidepressants (TCA), 35 iii. MAOI-Monoamine Oxidase Inhibitor, 36 iv. Electro Convulsive Therapy (ECT), 36 II. Bipolar Disorder, 38
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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a. Mood Stabilizers, 40 XXI. Psychosomatic/ Somatoform Disorder, 42 A. Psychosomatic Disorders, 42 B. Types of Somatoform Disorder/Psychosomatic Disorders, 43 XXII. Dissociative Disorder, 44 XXIII. Personality Disorders, 44 A. Cluster A: ODD/Eccentric, 45 a. Paranoid Personality Disorder, 45 b. Schizoid Personality Disorder, 45 c. Schizotypal Personality Disorder, 46 B. Cluster B: Dramatic/Erratic, 46 a. Antisocial Personality Disorder, 46 b. Borderline Personality Disorder, 47 c. Histrionic Personality Disorder, 47 d. Narcissistic personality Disorder, 47 C. Cluster C: Anxious/ Fearful, 48 a. Obsessive-Compulsive Disorder, 48 b. Dependent Personality Disorder, 49 c. Avoidant Personality Disorder, 49 d. Passive-Aggressive Personality Disorder, 49 XXIV: Cognitive/ Organic Mental Disorder, 49 A. Delirium vs. Dementia, 50 B. Types of Dementia C. Alzheimers Disease, 50 XXV. Eating Disorders, 55 A. Anorexia vs. Bulimia, 55 XXVI. Drug Addiction/Non-Alcoholic Substance Abuse, 57 A. Non-Alcoholic Abused Substances, 57 XXVII. Sexual Disorder/ Dysfunction, 59 XXVIII. Pervasive Developmental Disorder, 60 A. Autistic Disorder, 60 B. Attention Deficit Hyperactive Disorder, 61 C. Child Abuse, 61

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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PSYCHIATRIC NURSING A specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its art. Includes the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention of mental illness, health maintenance, management and referral of mental and physical health problems, the diagnosis and treatment of mental disorders and their sequela, and rehabilitation

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BASIC PRINCIPLES OF PSYCHIATRIC NURSING Accept and respect the client regardless of his behavior. Limit or reject the inappropriate behavior but not the individual Encourage and support expression of feelings in a safe and non-judgmental environment. Increase verbalization, decreases anxiety. Behaviors are learned. All behavior has meaning.

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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INTERDISCIPLINARY TEAM PRIMARY ROLES Psychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires 3year residency, 2-years of clinical practice, and completion of an examination. The primary function of the psychiatrist is diagnosis of, mental disorders and prescription of medical treatments. Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for groups of individuals. Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain a masters degree in mental health may be certified as clinical specialist or licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states. Psychiatric social worker: Most psychiatric social workers are prepared at the masters level, and they are licensed in some states. Social workers may practice therapy and often have the primary responsibility for working with families, community support, and referral. Occupational therapist: Occupational therapist may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning such as working with arts and crafts and focusing on psychomotor skills.

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Recreation therapist: Many recreation therapists complete a baccalaureate degree, but in some instances persons with experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time. Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients interests and abilities and matching them with vocational choices. Clients are also assisted in job-seeking and job-retention skills, as well as pursuit of further education if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate or masters level and may have different levels of autonomy and program supervision based on their education.

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3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health) I. Primary Objective: PROMOTION & PREVENTION A. Client and Family Teaching (Health Teaching) 1. Teaching adolescent in preventing contracting STDs CHLAMYDIA: #1 STD in the U.S. #1 Sign: Greenish & purulent urethral discharge. PID (Pelvic Inflammatory disease) #1 cause of sterility in women #1 Drug of choice Erythromycin 2nd drug of choice Cephalosporin 2. Teaching pregnant women relaxation techniques Objective: to prevent complication in labor, fetal distress, perineal laceration (also can be prevented by Kegels exercise)

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Stage I of labor (LAT-CAP) L atent C chest breathing A ctive A bdominal breathing T ransitionalent P ant blow breathing 3. Teaching couples on contraceptives BON (Barrier, Oral Contraceptive, Natural) Barrier - CONDOM Oral - Artificial Natural - not for M A M (Malnourished, Anemics & Menses irregular) 4. Conducting rape prevention classes is an example of primary level of prevention.

B. Herbal Medicines C. Psychosocial Support family/friends/peers Needs most support (ASA): Addicts, Suicidal, Alcoholics, Suicide = Mmajor depression, despair, hopeless, powerless Prone: Mmale Age bracket prone for suicide #1. Adolescent (identity crisis) 2. Elderly (ego-despair) 3. Middle age men (40 y.o. above) 4. Post partum depression (7 days/2-4 weeks) D. Giving Vaccines II. Secondary : Screening, Diagnosis & Immediate Treatment A. Screening > Denver Development Screening Test (DDST) #1 test for PDD Pervasive Development Ddisorder (PPD) 1. Autism: Aage of onset (3 y.o.) 2. ADHD: Aage of onset (6 y.o.) Diet: Finger Food (high caloric, high CHO)
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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Rx: (Dexedrine)

Ritalin

(Methylphenidate);

dextroamphetamine

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3. Conduct disorder: Aage of onset (6 y.o.)

B. Suicide Prevention/Intervention Impending signs of Suicide 1. Sudden elevation of mood/sudden mood swings 2. Giving away of prized possessions 3. Delusion of Omnipotence (divine powers) Used by SS (Suicidal, Schizophrenia) 4. When the patient verbalizes that the 2nd Gen TCA is working. less than 2-4 wks (telling a lie) Suicide Interventions: 1. One-on-one supervision and monitoring 2. No suicide contract 24 hrs monitoring - Patient is required to verbalize suicidal ideas 3. Non metallic/plastic/sharp objects: ex. belts, curtains 4. Avoid dark places C. Case Finding (Epidemics)/Contact Tracing (STDs) D. Crisis Intervention Objective: Tto return the client to its normal functioning or pre crisis level. Duration: (4-6 wks) Disorganization is a phase in the crisis state which is characterized by the feelings of great anxiety and inability to perform activities of daily living
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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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A patient in crisis is passive and submissive, so the nurse needs to be active and should direct the paient to activities that facilitate coping. Types of Crisis: 1. Developmental Maturation Crisis - Adolescence (identity crisis) - Mid-life crisis; - Pregnancy - Parenthood 2. Situational / Accidental crisis - Most common: Ddeath of a loved one NSG DX: Ineffective Individual Ccoping/ Denial - ex. murder, abortion , rape and fire 3. Adventitious calamity, disaster ex. World War I & II, epidemic, tsunami In a DISASTER 1st assess/survey the scene

E. Emergency drugs and antidotes DRUGS/ DISEASE Heparin Warfarin (Coumadin) Mg Sulfate Nubain (best), Morphine Fibrinolytic / Thrombolytic *(Neuroleptic Malignant Syndromes (NMS) Action / Effect Anticoagulant Anticoagulant Anticonvulsants Narcotics Dissolves clot ANTIDOTES Protamine Sulfate Vit. K Calcium gluconate Naloxone (Narcan)

Amicar (Aminocaproic acid) #1 Cardinal Sign : Dantrolene High Fever / (Dantrium), Hyperthermia Bromocriptine (Parlodel) Effect: antiparkinsonian, anti-

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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prolactin, antipsychotic Hypertensive crisis Antidepressant Ca channel blocker (MAOI intoxication) intoxication Suffix:(-dipine) Anxiolytics, Sedatives Sedative hypnotic/ Flumazenil Suffix: zepam, -zolam Minor tranquilizer (Romazicon) Tensilon Anticholinesterase & Atropine Sulfate (Endrophonium): Miotic (ATSO4) Anticholinesterase intoxication, Pilorcarpine (Pilocar) intoxication : Miotic III. Tertiary Objective: Rrehabilitation, which start upon admission A. Occupational Therapy - Usually use behavior modification for PDD (Pervasive Developmental Disorders), anorexia & depression - Also use fine motor rehabilitation for Post M.I. & Post CVA B. Vocational Skills (Entrepreneur skills) C. Aftercare Support follow-up. Needed by: addicts & residual schizophrenia due to remission & exacerbation

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CRITERIA OF MENTAL HEALTH (Jahoda, 1953; Staurt and Sundeen, 1995)

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Reality perception: Aability to test assumptions about the world by empirical thought; includes social sensitivity (empathy) Growth, development, & self-actualization (by Maslow) which includes fully functioning person (by Rogers) Autonomy: Iinvolves self- determination, self- responsible for decisions, balance between dependence and independence, and acceptance of the consequences of ones action Positive attitudes toward self; includes self-identity, self-acceptance, selfawareness, belongingness, security and wholeness

COMPONENTS OF ASSESSMENT OF MENTAL STATUS SENSORIUM: Consciousness? Orientation? Attention? Concentration? Comprehension? Example: Disorientation & Confusion ( Dementia) APPEARANCE: Appropriateness? Grooming? Rigidity? Mannerisms? Example: Poor Grooming (Suicidal Patients, Schizophrenia and Manic Depression) AFFECT / MOOD: Appropriateness? Swing? Duration? Intensity? Example: Flat Affect: Schizophrenia & Major Depression. Seen also in Parkinsons Disease & Myasthenia Gravis. Labile Affect: Manic Depression or Bipolar Disorder THOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions? Delusions? Hallucinations? Example: Ddelusion of grandeur (manic), delusion of omnipotence ( schizophrenia), delusion of persecution & delusion of reference (paranoid delusions) THOUGHT PROCESS: Ability to understanding abstract/symbols? Example: Mmagical thinking and animism of Schizotypal personality SPEECH: Coherency? Relevance? Meaning? Quality/Quantity? Example : Slurring of Speech ( alcoholism) and pressured speech (manic depression or bipolar

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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disorder)

DSM V (Diagnostic and Statistical Manual for Mental Health) Axis I II III IV V Clinical Syndrome (S&Sx) Personality Disorders Pathological Disorders Environmental & Psychosocial stressors Global Functioning (assessment)]

CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); FocusIntrapsychic process (conflicts, anxiety, defense mechanisms, impulses).0 BEHAVIORAL FRAMEWORK: Focus- learned behavior; Pavlovs Theory: Classical Conditioning; Skinners Theory: Operant Conditioning. INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); FocusConscious human experiences BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus Disease approach, syndromes, diagnoses, etiologies. PSYCHOSOCIAL THEORY OF ERIC ERIKSON Most commonly used theory by health professionals.

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Describes the human cycle as a series of eight EGO developmental stages from birth to death; Focus: PSYCHOSOCIAL TASKS throughout the life cycle. STAGES OF PSYCHOSOCIAL DEVELOPMENT: AGE Infancy (0-18 mo) Toddler (18 mo-3 yrs) Preschool Age (3-6 yrs) School Age (6-12 yrs) Adolescence (12-20 yrs) Early Adulthood (20-35 yrs) Middle Adulthood (35-65 yrs) PSYCHOSOCIAL TASKS Trust vs. Mistrust Autonomy vs. Shame and Doubt Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role confusion Intimacy vs. Isolation Generativity vs. Stagnation Most common task of 40 y/o includes developing responsibility over their own lives Integrity vs. Despair 76 y/o male who has a good ego integrity is preoccupied w/ death

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Later years / Old Age (65 yrs)

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PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY OF SIGMUND FREUD Infancy: Oral Phase; Stage of the Id Toddler: Anal Phase; Stage of the Ego Preschooler: Phallic Phase; Stage of the Superego (conscience) Attachment of the child to the parent of the opposite sex and jealousy toward the parent of the same sex Oedipal Complex: Attachment of the son to his mother and jealousy toward the father. Electra Complex: Attachment of the girl to her father and jealousy toward the mother. Schooler: Latency phase; Stage of the Strict Superego Adolescent: Genital phase FREUDIAN THEORY COMPONENTS:
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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1. LEVELS OF AWARENESS:

Conscious Subconscious Watchman of the Personality Unconscious The one who molds the personality Storage bin of traumatic & meaningful memories. True desires & motives are here.
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Conscious Composed of past experiences, logical and governed by REALITY PRINCIPLE; are remembered and easily recalled or available to the individual Subconscious the Preconscious; composed of material that has been deliberately pushed out of conscious level; helps repress unpleasant thoughts or feelings and can examine or censor certain desires or thinking; can be recalled with some effort Unconscious Composed of the LARGEST BODY OF MATERIALthe thoughts, memories and feelings that are repressed and not available to the conscious mind, not logical and governed by PLEASURE PRINCIPLE and since it is usually painful and unacceptable to the individual, it cannot be deliberately brought unacceptable to the individual, it cannot be deliberately brought back into awareness unless in disguised or distorted form (dreams)

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2. SYSTEMS OF PERSONALITY, 3 AGENCIES OF THE MIND: Three Elements of Personality FUNCTION PRINCIPLE LANGUAGE PERSONALITY -Animal -Pleasure I want it Infant/child instinct when I want Principle

Id

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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-Survival of the fittest Ego -Balances (Mediator) the desire of the Id and Superego The ego acts as the integrator of the personality. -Induces guilt undoing Reality Principle

it. I can wait.

Adult

Superego

Conscience Principle

Thou shall not.

Parent
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IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENTS OF PERSONALITY Id + SE = Conduct Ddisorder and Antisocial Personality Disorder Id + SE = Obsessive Compulsive Disorder ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the reservoir of INSTINCTS, primitive drives governed by the PLEASURE PRINCIPLE and is SELF- CENTERED. The Ids says, I want, what I want, when I want it. EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS, The I that is shown to the environment and most in touch with REALITY and the MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID and the self- critical, prohibitive forces of the SUPEREGO and is directed by REALITY PRINCIPLE. This is the thinking- feeling part of personality. The Ego says, I would want to have it if only I can afford it; Not now, I am not yet ready; perhaps next week.

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS, controls, inhibits and prohibits impulses and instincts, is self- critical, and is called the CONSCIENCE or EGO IDEAL. The Superego says, I should not want that; It is not good to even wish for it.

ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT 1. Names of RN and patient 5. Purpose of a relationship 2. Roles of RN and patient 6. Meeting location / time 3. Responsibilities of RN and patient7. Condition for termination 4. Goals / Expectations 8. Confidentiality

FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)

A. Pre-interaction/Pre-orientation (For the Nurse) - Stage of Self-Awareness Tto prevent Counter Transference #1 CORE VALUE OF Psychiatric Nursing

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B. ORIENTATION (INITIATION)

Assessment of problems, needs, expectations of clients Identify anxiety level of self and client Set goals of relationship. Define responsibilities of nurse and client. Stage of testing. Establish boundaries of relationship. Stress confidentiality. Contract 2 famous psychiatric contracts: 1. No suicide contract Mmajor depression = emergency TWO definitions of no suicide contract: A. 24 hrs monitoring B. Vverbalization to the nurse of all suicide ideas
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN
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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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2. Diet contract Eeating disorder - The start of termination phase: Good morning, full name, RN, shift, session, date start & end. C. WORKING PHASE Promote acceptance of each other Accept client as having value and worth as a unique individual. - Stage of resistance - Counter transference phase - Most difficult phase -- NCP is on going - Identification of the problem/exploration - The #1 Psychiatric Core Value is Consistency Ffor manipulative patients Be consistent to patient with: BAAAM COPS B orderline C onduct d/o A ntisocial O oral/eating disorder A lzheimers P aranoid A utistic S uicidal M anic Use therapeutic and problem- solving techniques Maintain PROFESSIONAL, therapeutic relationship Keep interaction reality- oriented- here and now Provide ACTIVE LISTENING and REFLECTION of feelings Use non- verbal communication to support client Recognize blocks to communication and work to remove them FOCUS on clients: Confronting and working through identified problems Problems- solving skills Increasing independence Help client develop alternative, adaptive coping mechanisms Personal biases (manifestation by counter-transference & vice versa) are seen during working phase

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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D.

TERMINATION Plan for termination of relationship early the relationship - Stage of Separation Anxiety Signs & symptoms: Rregression: Ttemper tantrums, thumb sucking, apathy, fetal position when crying. - Phase of prognosis Eevaluation Maintain boundaries Anticipate problems of termination: Increased dependency on the nurse Recall of previous negative experience- rejection, depression, abandonment, etc. Regressive behaviors Discuss clients feelings and objectives achieved THERAPEUTIC COMMUNICATION

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DEFINITION: Continuous, dynamic process of SENDING and RECEIVING MESSAGES by various verbal or non- verbal means (words, signals, signs, symbols) utilized in a goal- directed professional framework.

THERAPEUTIC COMMUNICATION TECHNIQUES a. Offering of self safety, service, comfort I am here. I will sit here beside you. I will lead you to the group therapy session. *Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with moderate lacerations to both wrists. Surrounded by broken glass, she sits staring blanking at her bleeding wrist while staff members call for an ambulance. The best way the nurse should do is to approach Ursula slowly while speaking in the calm voice, calling her name and telling her that

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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the nurse is here to help her. This approach provides reassurance for a patient in distress. b. Reflection: (mirror of feelings) It must be difficult for you. You seem angry. You seem concerned. When patient with symptoms of severe depression says to the nurse I cant talk; I have nothing to say. And continues being silent. The most appropriate response of the nurse is to say, It may difficult for you to speak at this time; perhaps you can do so at another time. This response will convey that the nurse is willing to wait for the patients readiness to engage in conversation. Daughter of patient newly diagnosed w/ Alzheimers says, I cant be. Nobody in the family is senile, correct 5response of RN includes statement like, It sounds as if you are shocked over the diagnosis. c. Elaboration/Exploration Tell me more about your feelings Everyone is on my back. My husband says, I dont do anything right, & my boss wants me to do things differently. RNs response to elaborate feelings includes statement like, Have you discussed this with your husband about how to cope with these problems? Tell me. Appropriate response for an 80 y/o who says, I told my children that Im ready to die. Includes statement like Tell me about your feelings & I will stay w/ you.

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d. Clarification used in neologism and word salad Schizophrenia, Alzheimers, Manic)

SAM (seen in

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What do you mean by? (Used in Neologism and word salad) I could not follow you. (Used in flight of ideas and looseness of association) The ground is watching us., appropriate intervention includes clarify the meaning of the word. Brilliant & charming patient says, Ill be better off dead. Best response of the RN includes asking questions like, Do you have plans of suicide? Pt says, Id like to take you out & give you a good show. best response by the RN is asking pt, What do you mean by a good show?

e. Reality Orientation/Reality Testing - Nsg Dx: Altered Sensory Perception - Delusion; Hallucination, Illusion & delusion Client: Help! Help! There are spiders on my back! Nurse: I dont see spiders but for you that is real. Alcoholic pt with delirium tremens states, There are spiders crawling on my back. The appropriate response of the nurse would be, there are no spiders, its only part of your illness.
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f. Giving Leads Aha..thenmmmh go on yes g. Therapeutic Silence h. Paraphrasing/restating repeating


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Repeats the MAIN IDEA; restate what the client says. (Patient: I cant believe I cannot go home today. Nurse: You cant believe that you cant go home today?) i. Summarizing recap Nurse: Today you have described your understanding of how you feel when you are upset with your son. j. Validation interpret Client: I see a shadow. Nurse: Youre frightened. A patient admitted to be listening to voices should be assessed by asking, What does the voice tells you? I know that Prof. Draper tried to rape me, rape my mind...& hes still trying to rape me, correct of RN includes questions like Are you frightened being unable to control your thoughts? Post-menopausal woman says, Im pregnant by God in heaven. Appropriate response by the nurse includes statement like, You believe something special happened to you? It must be frightening to feel that way. is an appropriate response for a suspicious pt saying, I think that my food is being poisoned RNs correct response of pt w/. OCD who checks door 10-15 times includes statement like, It sounds as if you have much anxiety.

k. Open-ended question / broad openings Questions NOT answerable by YES or NO; encourages further or broadened communication. How are you? Hows your day? What are your favorite things?

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BLOCKS TO THERAPEUTIC COMMUNICATION a. Never use why it demands an explanation and also anxiety provoking b. Closed Ended Question questions answered by yes or no Note: Tthe only therapeutic closed-ended question Ssuicidal pt. Are you planning to commit suicide? Confrontation c. False Assurance Ddo not worry Tto patient who are dying & w/ incurable illness You have the best doctor; everything will be all right. Relax that is nothing to worry about. d. Agree/disagree never argue with client You are right in doing that. / You should not think that way. e. Belittling the patient CHANGING THE SUBJECT f. Non therapeutic silence/touch g. Advising never advise because they are sometimes persona; opinions I believe it would be better if you h. Stereotyping

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BEHAVIORAL THERAPY A. TERMINOLOGIES STIMULUS: Aany event affecting an individual PROBLEM BEHAVIOR: Ddeficient, excessive, condemned, unwanted behavior OPERANT BEHAVIOR: Aactivities that are strongly influenced by events that follow them. TARGET BEHAVIOR: Aactivities that the nurse wants to develop or accelerate in the client.

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REINFORCER: Aa reward positively or negatively influences and strengthens desirable behaviors. POSITIVE REINFORCER: Aa desirable reward produced by specific behavior (TV time after doing homework) NEGATIVE REINFORCER: Aa negative consequence of a behavior (Spanking child for wetting the floor)

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A. Classical Conditioning (pairing of two stimuli in order to gain a new learning behavior by Ivan Pavlov) 1. Acquisition (newly acquired behavior or the by product of classical conditioning). 2. Extinction B. Operant conditioning Burrhus Skinner - used in Behavior Modification 1. Positive reinforcement (Reward Orientation) Token Economy use tokens as a source of reward. Used in eating disorders and depression > Token economy is also effective for toddlers 2. Negative Reinforcement (Punishment Orientation) Aversion Therapy/Aversion Technique Behavioral Treatments 1. Desensitization gradual exposure to the feared object -- #1 treatment for phobia 2. Flooding/.Implosive Therapy sudden exposure 3. Relaxation Technique light stroking = labor - Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation) 4. Biofeedback mind over matter. Ex. HPN BP, palpitations, headache 5. Guided Imagery (Child) & Visualization (Adult)
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GROUP THERAPY A. DEFINITION: Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or undesirable behavior. Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy. 8-10 patients are the optimal number of patients in a group. B. TYPES OF GROUPS 1. Structured Goals: Ppre- determined Format: Cclear and specific Factual material: Ppresented Leader: Rretains control

2. Unstructured 1. Goals: Nnot pre- determined. Responsibility for goal is shared by group and leader 2. Format: Discussion flows according to group members concern 3. Materials and topics are not pre- elected. 4. Leader: Nnondirective 5. Emphasis: Mmore on FEELINGS rather than facts C. ADVANTAGE OF GROUP THERAPY 1. Economical: Lless staff used. 2. Increased feelings of closeness Reduction on feelings of being alone. 3. With feedback group Corrects distortions of problems Builds self- image and self- confidence Increases reality- testing opportunities Gives info on how ones personality and behavior appear to others 4. With opportunities for practicing alternative behaviors and methods of coping with feelings
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5. Provides attention to reality and provides development of insight into ones problems by expressing own experiences and listening to others in groups D. PRINCIPLES OF GROUP THERAPY 1. Verbalization: Members express feelings and group reinforces appropriate communication. Desired outcome of group therapy includes verbalization of feelings rather than acting them out 2. Activity: Provides stimuli to verbalization and expression of feelings. 3. Support: Members gain support from one another through interaction, sharing and communication. 4. Change: Members have opportunity to try out new and desirable behaviors in group, supportive setting to effect change. E. PHASES OF GROUP THERAPY 1. Initial Phase Formation of group Setting and clarification of goals and expectations Initial meeting, acquaintance and interaction 2. Working Phase Confrontation between members Ccohesiveness Identification of problems Pproblem- solving processes In a group therapy when one client says to another, Maybe youre taking on someone elses problems. this shows that they are in the working phase

3. Termination Phase Evaluation of goals attainment Support for leave- taking


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In group therapy if a client says, Leave me alone & get away from me., best action of the RN is to maintain distance from the pt. Behavior indicating that goal is met after socialization in a group therapy includes participation of each group member telling the leader about specific problems

DEFENSE MECHANISMS

REPRESSSION CONVERSION IDENTIFICATION SUBLIMATION RATIONALIZATION DISPLACEMENT SPLITTING REGRESSION INTELLECTUALIZATION DENIAL

SUPPRESSION DISSOCIATION/SYMBOLIZATION INTROJECTION COMPENSATION PROJECTION UNDOING REACTION FORMATION FIXATION ACTING-OUT FANTASY
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DEFENSE MECHANISMS Legend: DM means Defense Mechanism 1. REPRESSION Involuntary recall painful or unpleasant thoughts or feelings cause they are automatically & involuntarily pushed into ones unconsciousness. FORGETFULNESS Bblackout (alcoholic intoxication) blocking (Alzheimers/Dementia) Mmemory gaps Cconfabulation = making story to fill in memory gaps also used by Wernickes Korsakoffs = Vit. B1-thiamine, peripheral neuritis (tingling sensation) B6 Pyridoxine, B9 folic acid, B12 P. anemia.
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Ex. Sexually abused as a child blocks the experience from her consciousness and is confused about inability to respond sexually. SUPPRESSION used Willingly or voluntarily putting unacceptable selective inattention (moderate thoughts or feelings out of ones mind with the anxiety) ability to recall the thoughts or feelings at will. Ex. Voluntary forgetfulness or I rather not talk about it, right now! Transferring of mental conflict or emotional anxiety into physical symptom to release tension. Ex. A soldier experiences sudden blindness after witnessing his best friend dying from a grenade blast; Diarrhea before exam; suppress anger HPN Act of detaching of separating a strong emotionally charged conflict from ones consciousness. Ex. A woman raped found wandering a busy highway traumatic amnesia. An object, idea, or act represents another through some common aspect and carries the emotional feeling associated with the other. Ex. Engagement ring symbol of love; phobias Unconsciously, people use it to identify with the personality and traits of another. To preserve ones ego or self. Mimics/simulates external behavior , like fashion & fads Ex. Imitator, similar to role playing Attributing to oneself the good qualities of another. Incorporate feelings & emotions, values & beliefs, traits and personality. ingestion, internalization Ex. Acting & dressing like Jesus Christ Re-channeling of consciously intolerable or Socially Unacceptable Behaviors or impulses into personally or socially acceptable. Modify the issue, problem is still present and connected Ex. An aggressive person joins debate team

2. CONVERSION #1 DM: Ssomatic/somatoform disease

DISSOCIATION #1 DM: Mmultiple personality= destruction of ego

SYMBOLIZATION unconscious; #1 DM: Pphobias 3. IDENTIFICATION external DM: Ppreschooler

INTROJECTION INTERNAL DM: Ddepression & counter transference 4. SUBLIMATION

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COMPENSATION

5. RATIONALIZATION object #1 DM: Aanti-social disorder

PROJECTION person #1 DM: Pparanoid

6. DISPLACEMENT higher to lower

UNDOING OR RESTITUTION lower to higher DM: Obsessive Compulsive 7. SPLITTING

(behavior modification)++ The act of making up for a real or imagined deficiency with a specific behavior. Conscious or unconscious. Problem is not connected. Ex. An unattractive girl became a very good tennis player. - + Most common ego DM. Unconsciously used to justify ideas, actions and/or feelings with good acceptable reasons or explanation. Irrational/illogical excuses to escape responsibility. Rationalization is justifying ones actions which are based on other motives. It is usually seen among alcoholics. Ex. It wasnt worth it; anyway, it is all for the best. Student fails an exam, blames it on the poor lectures. Temporarily alleviates anxiety. Person rejects unwanted characteristics of self and assigns them to others.Projection is attributing to others ones unconscious wishes/fear. Usually it is observed in paranoid patients. Ex. Blaming others for own faults. scapegoat Mechanism that serves to transfer feelings such as frustration, hostility or anxiety from one idea, person or object to another. Ex. Yelling at a subordinate after being yelled at by the boss. Negation of previous consciously intolerable action or experience to reduce or alleviate feelings of guilt. Ex. Sending flowers after embarrassing her in public. Viewing people as all good, and others as all bad Impulsive = poor self-control Ex. Hx of drug addicts & alcoholics DM: Borderline (female)
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Person exaggerates or overdevelops certain REACTION FORMATION #1 DM: Ppassive-aggressive actions by displaying exactly the opposite personality disorder behavior, attitude, or feeling from what he or she normally would show in a given situation. OVERCOMPENSATION. Conscious intent often altruistic. Procrastinate Ex. Student hating her CI may act very courteously towards her. A. temporary retreat to past levels of behavior 8. REGRESSION that reduce anxiety, allow one to feel more comfortable. Ex. A 27 year old acts like a 17 y.o. on her first date with a fellow employee; smoking at parties chronic regression Permanent or persistence into later life of FIXATION interests and behavior patterns appropriate to an early age. Without stressors Ex. Chain smokers, alcoholics = oral fixation The act of transferring emotional concerns into 9. the intellectual sphere. Exaggeration of intellect. INTELLECTUALIZATION Person uses reasoning as a means to avoid confrontation. Ex. Dear John Letter the groom is trying to figure out with his room mate why his fiance changed her mind to avoid confronting her. Unconscious wish turned into reality ACTING - OUT Ex. Molested child wants to be comforted becomes psychologist = Oprah The unconscious refusal /avoidance to face 10. DENIAL #1DM: thoughts, feelings, wishes, needs, and/or reality Alcoholics, PTSD, incurable factors that are intolerable. Blocking the illness awareness of reality. Ex. things will get better, soon 14 y/o girl who is undergoing dialysis says, Whats good about this, is that after it I will look good & thin. This shows that the teen is denying her chronic illness Cancer patient saying, You might have
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mixed my result with other patients, is showing denial FANTASY DM: Schizoid Imagined events or mental images. Wishful thinking; Temporary flight from reality to anxiety. Ex. Daydreaming. (permanent flight from reality: autism)

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ANXIETY A. DEFINITION: Effective subjective response to an imagined or real internal or external threat. Perceived SUBJECTIVELY by the conscious mind is as a painful, diffuse apprehension or vague uneasiness, but the causative conflict or threats is not in the conscious mind or awareness. Low / mild level of anxiety is healthy and helps in individual growth and development. B. MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY: Clients ability to focus on what is happening to him in a situation. Mild: The perceptual field is wide allowing the client to focus realistically on what is happening to him. Alert senses, increased attentiveness, and increased motivation. Moderate: Another word is selective inattention. The perceptual field narrows and the client is able to partially focus on what is happening if directed to do so and can verbalize feelings of anxiety. Severe: The perceptual field is significantly reduced and the client may not be able to focus on what is happening to him and may not be able to recognize or verbalize anxiety. All senses affected; decreased perceptual field; drained energy; Learning and problem-solving not possible. Start of sympathetic symptoms: tachycardia, palpitations, hyperventilation (brown paper bag to prevent Respiratory Alkalosis) and cold clammy skin. Panic: The perceptual field is severely reduced and the client experiences feelings of panic and dread. Client overwhelmed and helpless; personality may disintegrate hallucinations and delusions.

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Pathological conditions requiring immediate intervention. Client may harm self or others. A patient stating, Sometimes I feel like Im going crazy & losing control over myself, is showing symptoms of panic attack POTENTIAL NURSING DIAGNOSES Ineffective Individual Coping Anxiety C. NURSING INTERVENTION IMPLEMENTATON: Identify anxious behavior and anxiety levels and institute measures to decrease anxiety at a level where learning can occur. Provide appropriate environment where environmental stress & stimulation are low (First nursing action): Structured, NON-STIMULATING, uncluttered SAFE from physical exhaustion and harm. STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical care if necessary. Establish PERSON-TO-PERSON relationship and maintain an accepting attitude: ACCEPT client. Show willingness to LISTEN. Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid forcing verbalization. Administer medication as directed and needed. The pharmacology therapy of choice is the ANXIOLYTICS-reduces anxiety so client can participate in psychotherapy. Assist to cope with anxiety more effectively. Assist to recognize individual strengths realistically Encourage measures to reduce anxiety: activities: relaxation techniques, exercises (DANCING, WALKING, JOGGING), hobbies, talking with support groups, desensitization treatment program Provide individual or group therapy to identify anxiety and new ways of dealing with it and develop more effective coping interpersonal skills. If patient can be redirected back to the topic after he gets anxious while the RN gives discharge teaching, it is an indication that discharge teaching can be resumed.

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TYPES OF ANXIETY DISORDER

1. Phobia 2. Obsessive Compulsive 3. Post Traumatic Stress Disorder (PTSD) 4. Generalized Anxiety Disorder (GAD) 5. Panic Disorder

PHOBIA AND PANIC DISORDER A. Extreme anxiety and apprehension experienced by an individual when confronted with feared object/ situation; commonly begins in early twentys (young adult) as a result of childhood environmental factors characterized by ORDER & RIGIDITY; use compensatory mechanism of the psychoneurotic pattern of behavior and development of symptoms permits some measure of social adjustment. B. PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early adult period C. TYPES OF PHOBIA Agoraphobia: Ffear of being alone, fear of open spaces or PUBLIC places where help would not be immediately available (trains, tunnels, crowds, buses) A client with agoraphobia who is already able to go outside the house indicates a positive response to therapy. Expected outcome for agoraphobia includes going out to see the mailbox Social phobia: Ffear of public speaking or situations in which public scrutiny may occur Simple phobia: Ffear of specific objects, animals or situations

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D. NURSING IMPLEMENTATION Recognize the clients feelings about phobic object/ situation Specific precipitants are present with phobia
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Avoid confrontation and humiliation; Provide constant support (Stay with client during an attack) if exposure to phobic object or situation cannot be avoided Do not focus on getting patient to stop being afraid Provide relaxation techniques Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for PHOBIA) . Administer antidepressants as ordered

OBSESSIVE-COMPULSIVE DISORDER A. A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts and repetitive acts; Unconscious control of anxiety by the use of rituals and thoughts 1. OBSESSION: Ppersistent, repetitive, uncontrollable thoughts 2. COMPULSION: Rrepetitive, uncontrollable acts of irrational behavior that serve NO rational purpose rigidity, rituals, inflexibility; the development of rituals permits some measure of social adjustment B. ASSESSMENT FINDINGS: Rritualistic, rigid, inflexible; with difficulty making decisions and demonstrates striving at perfection; use verbal and intellectual defenses C. NURSING IMPLEMENTATION: Provide for physical safety (1st); meet physical needs Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to interfere with ritual is after client has completed it.) Accept behavior but set limits on length and frequency of the ritual. Offer alternative activities; support attempts to reduce dependency on the ritual; guide decisions Provide structured environment, minimize choices Provide socialization, group therapy Administer CLOMIPRAMINE (ANAFRANIL) as ordered A Tricyclic antidepressant used in phobias, anxiety and obsessivecompulsive disorder; SIDE-EFFECTS/ ADVERSE REACTIONS: Ttachycardia, cardiac arrest, dizziness, tremors, seizures, CONTRAINDICATIONS: Ppregnancy, hypersensitivity;

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Interactions/Incompatibilities: Hypertensive crisis, convulsions, with MAOIs

POST-TRAUMATIC STRESS SYNDROME A. A disorder following exposure to extreme traumatic event (wars, rape, natural catastrophes) causing intense fear, recurring distressing recollections and nightmares B. ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts, feelings intense fear and horror, sleep disturbances. Depression, or irritability or outburst of anger Exaggerated startle response; Poor impulsive control Avoidance; Inability to maintain intimacy; Hypervigilance C. PRIORITY NURSING DIGNOSIS: Altered Sleeping Patterns Altered Skin Integrity Ineffective Individual Coping D. NURSING INTERVENTATION Encourage VERBALIZATION about painful experience. Show empathy; be non-judgmental; Help feel safe. Rational emotive-therapy; Allow to grieve Help client identify, label and express feelings safely Enhance support systems: Sself-help groups, family psychoeducation, and socialization. In a rape victim, a statement like, If I should not have worn that red panty, it wont happen to me, shows denial Statement of a rape patient who is beginning to resolve trauma includes, Im able to tell my friends about being raped. An RN needs further teaching about caring for a post-traumatic client when she keeps on asking the client to describe the trauma that caused patients distress after recovering from a PTSD. GENERALIZED ANXIETY DISORDER A. Description
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1. Generalized anxiety disorder is an unrealistic anxiety in which the cause can be identified. The two major types of precipitating factors for anxiety are: treats to one biologic integrity and treats to ones self-esteem. Anxiety is one of the defining characteristics of ineffective individual coping. A patient with anxiety disorder may exhibit difficulty in coping. 2. Physical symptoms occur B. Assessment 1. Restlessness and inability to relax 2. Episodes of trembling and shakiness 3. Chronic muscular tension 4. Dizziness 5. Inability to concentrate 6. Chronic fatigue and sleep problems 7. Inability to recognize the connection between the anxiety and the physical symptoms 8. Focus on the physical discomfort

PANIC DISORDER 1. Description a. The cause usually can not be identified. b. Panic disorder produces a sudden onset with feeling of intense apprehension and dread. c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur. 2. Assessment a. Choking sensation b. Labored breathing c. Pounding heart d. Chest pain e. Dizziness f. Nausea g. Blurred vision

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h. Numbness or tingling of the extremities i. A sense of unreality and helplessness j. A fear of being trapped k. A fear of dying L. Ffeelings of impending doom 3. Interventions a. Attend to physical symptoms b. Assist the client to identify the thoughts that aroused the anxiety and identify the basis for these thoughts. c. Assist the client to change unrealistic thoughts to more realistic thoughts. d. Uuse cognitive restructuring. e. Administer anti-anxiety medications as prescribed A client in panic disorder showing dilated eyes, trembling & says, I can no longer go further. Should be accompanied in her room & RN should stay w/ her for a while The goal of intervention in the care of the anxious patient is to enable him to develop his capacity to tolerate mild anxiety. A combination of behavioral and somatic approaches is effective in the management of anxiety. Therapeutic communication appropriate to patient showing signs of panic disorder includes providing a concrete direction ANXIOLYTICS/ANTI-ANXIETY Another word: Sedatives/Hypnotics/Minor Tranquilizer For: Delirium, anti-anxiety, insomnia ACTION: Increases GABA (gamma amino butyric acid) USES: Major use to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion; Used in neuroses, psychosomatic disorders, functional psychiatric disorders. DO NOT modify psychotic behavior. Most commonly prescribed drugs in medicine Greatest harm: Wwhen combined with ALCOHOL

I. Benzodiazepine Code: -ZEPAM/ZOLAM Action: Aanticonvulsant, muscle relaxant & anxiolytic

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Diazepam (Valium)* best for: Sstatus epilepticus , the best for delirium tremens (alcohol & cocaine withdrawal) Estazolam (Prosom) Alprazolam (Xanax) Chlorazepate (Tranxene) Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers) Advantage: Nnot hepatotoxic Lorazepam (Ativan)* 2nd drug for sundown syndrome Triazolam (Halcion)* Anti-insomnia Temazepam (Restoril)* Anti-insomnia Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly because of rebound grand mal seizure Midazolam (Dormicum) Prazepam (Centrax) Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens Clonazepam (Klonopin) Halazepam (Paxipam) Side Effects: #1 Vital sign to be monitored: Respiratory Rate due to its Lethal Side Effect; Respiratory Depression 1. Early decrease LOC Lethargic Late/Fatal decrease RR Respiratory Depression RR below 12 Avoid strenuous activities Antidote for Benzodiazepine intoxication: (ROMAZICON); an anxiolytic antagonist FLUMAZENIL

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II. Barbiturates Action: Uused as an anticonvulsant besides being a sedative Code: TAL / AL Secobarbital (seconal) Phenobarbital (luminal)* commonly used anticonvulsant barbiturate Methohexital (Brevital) Amobarbital (Amital)
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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III Atypical Anxiolytics Meprobamate (Equanil, Milltown) Chloral Hydrate (Noctec) Hydroxyzine (Atarax, Iterax, Vistaril)* anti emetic & antihistamine Diphenhydramine (Benadryl)* Antiparkinsons, Antihistamine, Anxiolytic (addictive) Zolpidem (Ambien, Stillnox) sleeping aid

1. SIDE EFFECTS DROWSINESS (Do not drive; assistance w/ walking; NO alcohol) Mental confusion (Evaluate mood, sensorium, affect) Habituation and increased tolerance Withdrawal symptoms: high doses & prolonged use (>6mo) PSYCHOTIC DISORDER: SCHIZOPHRENIA

Definition: Ssevere impairment of mental & social functioning with grossly impaired reality testing, sensory perception and with deterioration & regression of psychosocial functioning. A. ASSESSMENT FINDINGS (GENERAL SIGNS) THE FOUR As of SCHIZOPHRENIA ACCORDING TO BLEULER ASSOCIATIONS, LOOSE: Jjumping to different topics WITHOUT association or relevance AMBIVALENCE (Two opposing feelings toward others at the same time) AUTISM (withdrawal from environment and others) magical thinking, neologism, aloofness) AFFECT, FLAT (Inappropriate or no display of feelings)
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#1 HALLUCINATION of Schizophrenia is Auditory. THEORIES: 1. Iincreased dopamine coming from the substancia nigra 2. Trauma PTSD 3. Ddouble-bind theory 2 kinds of information/communication 4. Genetics 65% chances- if two parents are diagnose with schizophrenia 32.5% chances- if 1 parent is diagnosed with schizophrenia 5. Drug addicts and alcoholics: Hhigh probability for schizophrenia due to increase Delusions & hallucination DSM V Criteria for Schizophrenia: Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at least SIX (6) months. Patient with 5 admissions in 2 yrs is considered a chronic schizo.

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(+) POSITIVE SIGNS OF SCHIZOPHRENIA: DOPAMINE

Ddue to EXCESS

Do you know HILDDA PI? Hallucination, Illusion, Looseness of Association, Delusion, Disorientation & Agitation Paranoia & Insomnia Schizophrenic patient says, Pretty red dress, tomatoes are red is showing looseness of association
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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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(-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Ddue to LACK OF DOPAMINE Remember your POOR As? Poor judgment, Poor insight, Poor self care Alogia, Anergia, Anhedonia NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF SCHIZOPHRENIA: 1. Alteration in Thought Process; 2. Alteration in Content of Thought

OTHER NEGATIVE SYMPTOMS: All this signs & symptoms can also be seen in SAM (Schizophrenia, Alzheimers & Manic) 1. Neologism (creating NEW WORDS) vs. Word Salad (incoherent mixture of words) 2. Flight of Ideas (jumping from one RELATED topic to another): Ccommonly seen in MANIC patients, also in Schizophrenia. 3. Verbigeration (meaningless repetition of action words (Verb)) vs. Perseveration e.g. 1st stimulus correct response 2nd & following stimulus still responding to the 1st stimuli 4. Circumstantiality (beating around the bush; answers but delayed) vs. Tangentiality (did not answer the stimulus/ question) 5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting & Echopraxia (Commonly seen in AUTISM)

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B. PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES SCHIZOPHRENIA: 1. Risk for violence: Ddirected toward self or other (priority!!!)
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2. 3. 4. 5.

Self-care deficit Thought process, altered Sensory/perceptual alterations ( related to illusion, delusion & hallucination) Social isolation

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C. 5 (FIVE) TYPES OF SCHIZOPHRENIA:

1. PARANOID: Presenting sign is SUSPICIOUSNESS, ideas of persecution and delusions; sees environment as hostile and threatening. REMEMBER the 4 Ps: Projection (#1 defense mechanism), Proxemics( 7 feet away from the patient), Passive Friendliness (#1 attitude therapy: Nno touching, , no whispering & laughing) , delusion of Persecution (#1 delusion of Paranoid Schizophrenia) , A patient who says, The other staff members are laughing at my back. shows a paranoid delusion of schizophrenia. Schizophrenic says, Someone has placed a transistor in my brain, correct interpretation shows paranoid delusion Statement like, I dont like to eat meat because animal produced foods are Poisonous, shows suspicious paranoid type schizophrenia. Developmental MISTRUST) Stage FIXATION: ORAL PHASE (TRUST vs.

NURSING CONSIDERATION: 1. Consistency to build trust 2. Food: PACKED OR SEALED foods except canned goods: Nno metal 3. Social Isolation no group session when schizophrenic Paranoid who is suspicious saying, This place is meant for bugs & prison, In order to encourage trust, the patient should be involved in the plan of care. 2. CATATONIC: With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism.
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#1 Defense mechanism: Autism & mutism #1 Cardinal Sign of Catatonia waxy flexibility (cerea flexibilitas) -Ssimilar in children with autism - Most dangerous/serious type of schizophrenia may die from dehydration CATATONIC CHARACTERISTICS: - Catatonic stupor markedly slowed movement. - Catatonic posturing- bizarre or weird positions - Catatonic rigidity cementation/stone-like position - Catatonic negativism resistance towards flexion & extension - Catatonic hyperactivity or excitability: PRIORITIZED NURSING DIAGNOSIS: 1. Fluid & Electrolyte Imbalance 2. Altered Nutrition less than body requirement 3. Self Care Deficit

3. DISORGANIZED: Another word is Hebephrenic. Characterized with inappropriate behavior: Ssilly crying, laughing, regression, transient hallucinations (Auditory). All behaviors are similar with toddlers since they are anal fixated. Developmental Stage FIXATION: Anal Fixation #1 Defense Mechanism: Regression & Fixation 4. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia - has delusions & disorganized behavior but DOES NOT meet the critieria for the above sub types alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate) 5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative symptoms or odd beliefs or unusual perceptions. Undifferentiated type chronic schizophrenia must be referred to a program promoting
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social skills due to functional loss deficit. D. PRINCIPLES OF CARE 1. Maintenance of safety: Protect from altered thought processes. Respond to feelings, and not to delusions; Do not argue; Validate reality; remove from areas of tension Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that shows a need for further teaching is when shegoes to the room of a pt. who yells, Everyone, out of here, Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall and saying Dont talk to me, bastard. includes walking towards the pt & ask him who he is talking to. 2. Meeting of physical needs: May have to be fed / bathe initially 3. Establishment and maintenance of therapeutic relationship: Engage in individual therapy; Promote trust; Encourage expression by verbalizing the observed; Offer presence-Tolerate long silences 4. Implementation of appropriate family, group, social or diversional therapies Patients with schizophrenia need activities that do not require interaction, so solitary activities are preferred over team activities. Admission assessment of a Schizophrenic client reveals auditory hallucination, and drinking more than 6 L of water daily for past weeks, priority focus should be hyponatremia. Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing up when RN enters the room.

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ANTIPSYCHOTICS Another word: Neuroleptic / Major Tranquilizers USES: Schizophrenia, acute mania, depression and organic conditions; Nonpsychiatric cases: Nausea and vomiting, pre-anesthesia, intractable hiccups. Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence. Action: delusion, hallucinations, looseness of association to decrease levels of dopamine in the substantia nigra I. Phenothiazine Code: AZINE Fluphenazine (Prolixin)* Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia; Side effects: Ccauses also red orange urine In liquid form is usually put in a chaser Chaser: 60100 ml juice (prone or tomato); to prevent constipation & contact dermatitis; taken with straw (bite straw & sip) Mesoridazine (Serentil) Thioridazine (Mellaril)* ceiling dose/day: 800 mg Adverse Effect: Rretinitis pigmentosa Prochlorperazine (Compazine)* #1 commonly used anti emetic Compazine causes anticholinergic side effects Trifluoperazine (Stelazine)

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II. Butyrophenones Code: PERIDOL Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior Instruct patient taking Haldol to wear sunscreen

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Droperidol (Inapsine) III. Thioxanthenes Code: THIXENE

Chlorprothixene (Taractan Thiothixene (Navane)

IV. Atypical Antipsychotics

Code: DONE / ZAPINE or APINE

Olanzapine (Zyprexia) Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrascia I will need to monitor my blood level to continue my medication. shows a correct understanding of a patient while taking Clozaril. Loxapine (Loxitane) Risperidone (Risperidone) #1 drug for Korsakoffs psychosis Molindone (Moban) Aripiprazole (Abilify) newest antipsychotic drug

SIX COMMON ANTICHOLINERGIC ANTIPSYCHOTICS

SIDE

EFFECTS

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(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC RECEPTORS) CODE: BUCO PanDan anticholinergic S/Es 1. Blurring of Vision - sympathetic reaction (dont operate machinery); Mydriatic pupil dilate sympa IOP dont use in glaucoma

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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2. Urinary Retention (Post Partum, Autonomic Dysreflexia, paraplegia) Nursing Interventions: 1. Provide Privacy give bed pan 2. Sounds of dripping water faucet 3. Intermittent cold & warm compress 3. Constipation Nursing Interventions: 1. Prevent constipation fiber (residue) AG or roughage, prune/pineapple/papaya juice/ fruits 2. OFI 3. exercise 4. Orthostatic Hypotension/Postural Hypotension - take BP in supine, Fowlers & standing position. Difference of BP 15-20 mm Hg below S/Sx: Ppallor, dizziness Nursing consideration: Slowly change position Told patient to dangle feet first before standing

5. Pan Photosensitivity (photophobia) Nursing Intervention: 1. Use sun glasses, sun block, long sleeves or/and umbrella Patients taking antipsychotic should be instructed to wear wide brimmed hat when going outside 6. Dan Dry mouth/ Xerostomia Prioritized Nursing Intervention: Give (1) ice chips, (2) chewing gum, (3) sips of water
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ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS Extrapyramidal Symptoms (EPS) Common Signs & Symptoms: Definition of EPS: Rreversible side effect (except TARDIVE DYSKINESIA), which is a result of neurological dysfunction of the Extrapyramidal System. Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of extrapyramidal symptoms. 1. Akathisia another word: Mmotor restlessness 1-6 wks Signs of motor restless: Foot tapping, finger fidgeting, cant sit down for more than 15 minutes and pacing back & forth. Patient is unable to remain still Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl) 2. Dystonia #1 cardinal Sign: Ooculogyric crisis = involuntary rolling of eyeballs, neck shoulder, jaw and throat spasm (dysphagia) 2-5 days Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl)
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3. Pseudoparkinsonism - another word: Ddrug-induced Parkinsonism #1 sign: Ppill--rolling tremors. Other signs: Mmask-like face, flat affect, shuffling gait or festinating gait, cogwheel rigidity. DRUG OF CHOICE: #1 Artane (trihexyphenydyl) #2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL 4. Tardive Dyskinesia Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking, tongue rolling, protrusion of the tongue, vermicular or vermiform tongue rolling irreversible. This is an EMERGENCY!!! Symptoms of tardive dyskinesia include fly catchers mouth, tongue thrusting, facial grimacing, puckering of cheeks, and drooling of saliva. --administer Artane, Benadryl, Cogentin, Antiparkinsonian drug Akinesia absence of kinetic movements

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5.

ANTI- EPS MEDICATION CODE: PACABBA - Usually they are anticholinergic & antiparkinsonian drugs Procyclidine (kemadryl, kemadrin) Artane ( trihexyphenydyl) Cogentin (Benztropine mesylate) Akineton (biperiden Hcl) Bromocriptine (Parlodel) Benadryl (Diphenhydramine) Amantadine (Symmetrel) ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS: Neuroleptic Malignant Syndrome RARE, LIFE-THREATENING : (EXTREME EMERGENCY): #1 Cardinal Sign is High fever, tremors, tachycardia, tachypnea, sweating, hyperkalemia, stupor, incontinence, renal

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failure, muscle rigidity (Discontinue all drugs STAT; ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic measures). Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical emergency. ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel) Bromocriptine is both an Antiparkinsons & Anti prolactin

AFFECTIVE / MOOD DISORDERS MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss; Personality disorganization; Cognitive: Hhopelessness; Learned helplessness- hopelessness; Behavioral: Lloss of positive reinforcement; Biological: Ddecreased serotonin and norepinephrine *; Life stressors; and Integrative: chemical, experiential, behavioral variables

DEPRESSION: An abnormal extension or over elaboration of sadness and grief; oldest and most frequently described psychiatric illness; a pathologic grief reaction experienced by an individual who does not mourn The term depression is used in varied ways: a sign, symptom, syndrome, emotional state, reaction, disease or clinical entity. May be mild, moderate, severe, with (uncommon) or without psychotic features I. TYPES: Depressive Disorders, Manic-Depressive (Bipolar) Disorders, Suicidal Behavior

A. DEPRESSIVE DISORDERS: Depressive episode with no manic episodes 1. Major depression, single episode 2. Major depression, recurrent: Rrepeated episodes of major sadness or depression separated by long intervals, occurring in clusters or increasing with age*

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3. Dysthymia: Cchronic depressive mood problems occurring in the absence of a major depressive or organic or psychotic diagnosis. DIFFERENTIATION/CATEGORY: Moderate Depression crying at night - Dysthymia painful depression for 2 years *Severe Depression Crying at early morning, depression less than 2weeks *Major Depression Severe depression for more than 2 weeks * - both of them have the same characteristics BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION a. Affective: Anger, anxiety, apathy, bitterness, hopelessness, helplessness, sense of worthlessness, low self-esteem, denial of feelings b. Physiological: Ffatigue, backache, anorexia, vomiting, headache, dizziness, insomnia, chest pain, constipation, weight change, abdominal pains* c. Cognitive: Confusion, indecisiveness, ambivalence, inability to concentrate, pessimism, loss of interest, self-blame d. Behavioral: Altered activity level, over-dependency, psychomotor retardation, withdrawal, poor hygiene, agitation, irritability, tearfulness In a depressed patient, hostility is turned towards the self, while in manic patient, hostility is turned towards the environment. Depression in children results to anhedonia (energy loss & fatigue, decreased interest in previously enjoyed activities) like playing alone during recess.

DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following, most of the day, nearly daily, for 2 weeks: 1. Early morning depression 6. Feelings of worthlessness & 2. Loss of interest or pleasure ambivalence (fear of death vs. fear living) * (ANHEDONIA)* 7. Self care deficit* 3. Insomnia* 8. History of suicide* 4. Psychomotor retardation (slow movt) 9. Weight loss or gain 5. Fatigue or loss of energy (anemia) 10. Flat affect* 11. Constipation* Formatted: Font: 10 pt
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PREDISPOSING FACTORS: 1. Single, Annulled & Divorced 2. Loss of loved one (situational crisis) 3. SAD Seasonal Affective Disorder common on winter season (Nov.Feb.) or intimate months Seasonal depression occurs during winter and fall this is due to abnormal melatonin metabolism. Intervention for pt with seasonal affective disorder (SAD) during a depressed mood includes the use of broad spectrum light in high activity area. This produces high intensity color like broad day light. Also instruct the pt that the light source must be 3 ft away from the eye 4. Caucasians/Afro-Americans/Asians* 5. Alcoholics/Drug addicts* A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money & has history of alcohol abuse is at risk for suicide 6. Protestants 7. Incurable Illness* 8. Post partum depression 9. Schizophrenia* Prone: Mmale Age bracket prone for suicide #1. Adolescent (identity crisis) 2. Elderly (ego-despair) 3. Middle age men (45 y.o. above) 4. Post partum depression (7 days/2-4 weeks)

Suicide and Self-destructive Behavior Suicide is never a random act. Whether committed impulsively or after painstaking consideration the act has both a message and a purpose. In general the purpose or reason for suicide is to escape; to get away or end an intolerable situation, crisis, difficulty, or relationship, e.g., escaping a terminal illness, avoiding being a burden to others, resolving an untenable family situation, or to avoid punishment or exposure of socially or personally unacceptable behavior.
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Self-destructive behavior is action by which people emotionally, socially and physically damage or end their lives. Typical behavior are biting ones nails, pulling ones hair scratching or cutting ones wrist. A complete suicide is the most violent self-destructive behavior.

Levels of self-destructive behavior: 1. Chronic self-destructive behavior e.g. smoking, gambling, self-mutilation 2. Suicidal threat a threat more serious than a casual statement of suicidal intent and accompanied by behavioral changes, e.g., mood swings, temper outbursts, decline in school or work performance 3. Suicidal gesture more serious warning signal than a threat that maybe followed a suicidal act that is carefully planned to attract attention without seriously injuring the subject 4. Suicidal attempt a strong and desperate call for help involving a definite risk. Cognitive styles of suicidal patients: 1. Ambivalence. They have 2 conflicting desires at the same time: T to live and to die. Ambivalence accounts for the fact that a suicidal person often takes lethal or near-lethal action but leaves open the possibility for rescue. 2. Communication. Some, people cannot express their needs or feelings to others, or when they do, they do not obtain the results they hope for. For them, suicide becomes a clear and direct, if violent, form of communication. Demographic Variables suicide rates are higher among the following: 1. 2. 3. 4. Single people Divorced, separated or widowed People who are confused about their sexual orientation People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss of social status or who are facing the threat of criminal exposure 5. Caucasians, Eskimos and Native Americans 6. Protestants or those who profess no religious affiliation
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Clinical variables: 1. People who have attempted suicide before 2. People who have experienced the loss of an important person at some time in the past or the loss of both parents early in life, or the loss of or threat of their spouse, job, money or social position 3. People who are depressed or recovering from depression or a psychotic episode 4. Those with physical illness, particularly when the illness involves an alteration of body images or lifestyle 5. Those who abuse alcohol or drugs 6. Those who are recovering from a thought disorder combined with depressed mood and / or suicidal ideation ( hallucinations that tell them to kill or harm themselves) Management people bent on suicide almost always give either verbal or nonverbal clues of their intent. They actually make a powerful attempt to communicate to others their hurt ad desperation. They are crying out for help. 1. A lethality assessment scale (Table 2) is an attempt to predict the likelihood of suicide. Table 2: Lethality Assessment Scale Key to Scale 1 Danger to Self No predictable risk of immediate suicide Typical Indicators Has no notion of suicide or history of attempts, has satisfactorily social support network, and is in close contact with significant others Person has considered suicide with low lethal method; no history of attempts or recent
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2 Low risk of immediate suicide

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serious loss; has satisfactorily support network; no alcohol problems; basically wants to live

3 Moderate risk of immediate suicide Has considered suicide with high lethal method but no specific plan or threats; or has plan with low lethal method , history of low lethal attempts, with dysfunctional family history and reliance on Valium or other drugs for stress relief; is weighing the odds between life and death

4 High risk of immediate suicide

5 Very high risk of immediate suicide

Has current high lethal plan, obtainable means, history of previous attempts, has a close friend but is unable to communicate with him or her a drinking problem; is depressed and wants to die

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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Has current high lethal plan with available means, history of high lethal suicide attempts, is cut off from resources; is depressed and uses alcohol to excess, and is threatened with a serious loss, such as unemployment or divorce or failure in school age more in elderly and adolescents

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General guidelines the general task of the nurse is to work with the client to stop the constricted processing of suicidal thinking long enough to allow the client and the family to consider alternatives to suicide. a. Take only threat seriously b. Talk about suicide openly and directly c. Implement basic suicide precautions: Check on the client at least every 15 minutes or require the client to remain in public places Stay with the client while all medications are taken Search the clients belongings for potentially harmful objects. Make the search in the clients presence and ask for the clients assistance while doing so Check articles brought in by visitors

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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Allow the client to have regular food tray but check whether the glass or any utensils are missing when collecting the tray Allow visitors and telephone calls unless the client wishes otherwise Check that visitors do not potentially dangerous objects in the room d. In addition to the above, maximum suicide precautions mean: Provide one-to-one nursing supervision. The nurse must be in the room with the client at all times Maintain the clients safety in the least restrictive manner possible Do not allow the client to leave the unit for test or procedures Serve the clients meals in an isolation tray that contains no glass or metal silverware e. Expect that the client will be experiencing shame, and work to assists the client toward self- acceptance f. Relieve the clients obvious immediate distress g. Find out what, in the clients view, the most pressing need is h. Assume a nonjudgmental, caring attitude that does not engender selfpity in the client i. Ask why the client chose to attempt suicide at this particular moment. The answer will shed light on the meaning suicide has for this patient and may provide information that can lead to other helpful interventions j. Decide if a no-harm, no suicide contract will be used k. Be careful not to encourage staff behaviors that give clients or staff members a false sense of security l. Do not make unrealistic promises m. Encouraged the client to continue daily activities and self-care as much as possible n. Decide with the client which family members and friends are to be contact and by whom o. Be prepared to deal with family members who may be confused, angry or uninterested p. Evaluate the clients need for medication q. Evaluate the plan developed in collaboration with the client and arrange for appropriate follow-up

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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r. Monitor your personal feelings about the client and decide how they may be influencing your clinical work s. Work with other team members to evaluate the issues fully t. Do a body examination u. Recognize that people can and have hanged or strangled themselves with shoelaces, brassiere straps, pantyhose, robe belts, etc. 2 LETHAL METHODS OF SUICIDE: 1. Low-risk = slashing of the radial pulse (more o females) 2. High-risk = drowning, gun shot, hanging, jumping from a very high place/building, overdose of tranquilizer (Midazolam & Dormicum)

SUICIDAL BEHAVIORS: SUICIDAL GESTURE: Ddirected toward the goal of receiving attention rather than actual self-destruction; b) SUICIDAL THREAT: Ooccurs before the overt suicidal activity takes place: Will you remember me when I am gone, Take care of my children; c) SUICIDAL ATTEMPTS: Aany self-directed actions taken by the individual that will lead to death if not interrupted. A most suicidal person has made a specific plan, and has the means readily available. Best question to be asked after a patient who recovers from an overdose of pills includes asking Do you still want to end your life?

IMPENDING SIGNS OF SUICIDE: 1. Sudden elevation of mood/sudden mood swings* When a depressed patient suddenly becomes cheerful, it means that the patient is recovering from depression and is in danger of committing suicide. 2. Giving away of prized possessions* 3. Delusion of Omnipotence (divine powers)

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Used by SS (Suicidal, Schizophrenia) 4. When the patient verbalizes that the 2nd Gen TCA is working. less than 2-4 wks ( telling a lie) Suicidal attempts are common when client is strong enough to carry out a suicidal plan, usually 10-14 days after start of medication, and after ECT USUAL TIME FOR SUICIDE: 1. Early in the morning RATIONALE: Tthe depression at this time is HIGH 2. In between nursing shifts RATIONALE: Nnurses at this time are very busy NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self STEP BY STEP PRIORITIZE NURSING INTERVENTIONS: 1. One-on-one nursing monitoring/intervention (never leave the client)* 2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)* 3. Offering of self (best therapeutic communication)* 4. No metallic objects 5. No sharp objects 6. Needs stimulus bright room Rationale: to see suicidal acts 7. Avoid religious music (increases guilt) and love songs = non-suggestive song is needed 8. Check for impending signs of suicide = sudden elevation of mood; #1 sudden mood swings A female patient who becomes euphoric for no apparent reason shows a behavior that indicates recovery from depression, which increases the risk for suicide. 9. Activities focus on self-care 10. Join group therapy Depressed patients usually turn their hostile feelings towards themselves. Providing an activity that serves as an outlet for these aggressive feelings will make the patient feel less guilty. During family therapy, a mother asks, How long will my daughters have suicidal thoughts? appropriate response of the RN- Your daughter will go on to view suicide as a way of
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coping. 11. Monitor in giving medication do not leave patient after giving medication for 30 minutes. Check under the tongue & pillow 12. Monitor patient in CR, between shift & during endorsement 13. #1 Attitude Therapy: Kind Firmness 14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS 1st SSRI (Selective Serotonin Reuptake Inhibitor) A 2nd Second Gen. TCA 3rd MAOI 4th ECT (last resort) 15. Meet physical needs: Promote eating, rest, elimination Promote self-care whenever appropriate / possible 16. Support self-esteem: Warm and consistent care Being patient with clients slowness Simple tasks that increase success and self-esteem and imply confidence in capabilities Example: Self care activities that will not easily tire the patient. Rationale: Depressed patients have fatigue. 17. Decrease social withdrawal: Ssit with client during quiet times; introduce to others when ready The priority focus for a suicidal patient in the ER with a slash in her wrist is her physiologic homeostasis. Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-up and saying, My life is ruined now.

ANTIDEPRESSANTS or THYMOLEPTICS

I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS Action: Balance Serotonin gradual effect (usually 2 weeks) Effect: 2 wks.

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Code: XETINE/ODONE Fluoxetine HCl (Prozac) dry mouth (xerostomia) Paroxetine HCl (Paxil) Trazodone (Desyrel)) adverse effect: Ppriapism (prolonged use) Nefazodone (Serzone) Fluvoxamine (Luvox) Sertraline (Zoloft) causes GI upset (diarrhea, insomnia): always with meals Venlafaxine (Effexor) Citalopram (Celexia) Common Side Effects: 1. Weight Loss 2. Insomnia (single am dose) Nursing Considerations: 1. Ffor insomnia: a. Induce sleep thru: 1. Wwarm bath (systemic effect) 2. Warm milk/banana (active substance: tryptophan) 3. Massage b. Give meds in single AM dose Antidepressants are best taken after meals

II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by presynaptic neurons or it balances Serotonin & Epinephrine levels. Effect: 2-4 wks. Code: PRAMINE/TRYPTILLINE Clomipramine HCl (Anaframil) #1 for OCD* Imipramine (Tofranil)* the best drug for enuresis Amitryptilline (Elavil) Protryphilline (Vivactil) Maprotilline (Ludiomil) Norpramine (Desipramine) #1 antidepressant for elderly depression. RATIONALE: Ffewer anticholinergic S/E
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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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Nortryptilline (Pamelor, Aventyl) Trimipramine ( Surmontil) Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: Ggrand mal seizure Doxepine (Sinequan) Amoxapine (Asendin) Common Side Effects: 1. Sedation (at night) 2. Weight gain Nursing Consideration: 1. Give meds at night # 1 adverse effect cardiac dysrhythmias #1 screening test before taking TCA ECG When a depressed client taking TCA shows no improvement in the symptoms, the nurse must anticipate the physician to discontinue TCA after two weeks and start on Parnate. Nursing intervention before giving the drug includes checking the BP. III. MAOI MONO AMINE OXIDESE INHIBITOR ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) CNS stimulation Effect: 2 weeks CODE: PAMMANA Parnate (tranylcypromine) Marplan (Isocarboxacid) Mannerix (Moclobemide) *the newest MAOI Nardil (Phenelzine SO4) CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS 1. Tyramine rich-food, high in Na & cholesterol Hypertensive Crisis 1. Aged cheese (except cottage cheese, cream cheese), Cheddar cheese and Swiss cheese are high in tyramine and should be avoided. 2. Canned foods such as sardines, soy sauce & catsup

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3. Organ meats (chicken gizzard & liver) & Process foods (salami/bacon) Na 3. Red wine (alcohol) 4. Soy sauce 5. Cheese burger 6. Banana, papaya, avocado, raisins (all over ripe fruits except apricot) 7. Yogurt, sour cream, margarine; 8. Mayonnaise 9. OTC decongestants 10. Pickled foods, Pickled herring Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver, meat tenderizer, , sausage, chocolate, licorice, yeast, sauerkrauts, Food safe to give includes fresh fish, Cream, Yogurt, Coffee, Chocolate , Italian green beans, sausage, yeast,

(tumor in

Antidote: CALCIUM CHANNEL BLOCKERS (-DIPINE) 1. Verapamil (Calan) 2. Phentolamine (Regitine) also the #1drug for Pheochromocytoma the medulla)

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IV. ELECTROCONVULSIVE THERAPY (ECT) ECT is passing of an electric current through electrodes applied to one or both temples to artificially induce a grand mal seizure for the safe and effective treatment of depression. ECTs mechanism of action is unclear at present

Advantages: Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of major depressive episode with vegetative aspects - Best therapy for major depression (last resort) - Invasive - Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a grand-mal seizure lasting 30-60 secs.

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- 6-12 treatments, every other day - Before ECT a major depressed client undergo the ff meds: 1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) 2 wks 2. Antidepressants TCA 2nd Generation 2-4 wks 3. MAOi 2 wks 4. ECT (last resort) Side Effects: 1. Temporary RECENT Memory Loss ANTEROGRADE amnesia Intervention: Rre-orient client to 3 spheres 2. confusion/disorientation (usually 24 hours) 3. Headache 02 demand, cerebral hypoxia 4. Muscle spasm 5. Wt. gain (stimulate thalamic/limbic appetite)

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Contraindicated: 1. PPPP Post MI, Post CVA, pacemaker, pregnant women 2. Neurologic problem Alzheimers, degenerative disorder 3. Brain tumor, weakness of lumbosacral spine
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A. Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery: 1. Informed Consent if client is coherent, if not a guardian may sign the consent forms. 2. No metallic objects 3. No nail polish to check peripheral circulation 4. No contact lenses it may adhere to the cornea 5. Wash & dry hair

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6. Give following medications BEFORE ECT: a. Atropine sulfate anticholinergic PRIMARY purpose to dry secretions and prevent aspiration SECONDARY purpose to prevent bradycardia (vagolytic) b. Phenobarbital (Luminal), Methohexital (barbiturate Na) minor tranquilizer also an anticonvulsant c. Succinylcholine (Anectine) muscle relaxant 7. Priority vs. to focus ABC; check RR 12 less; LOC 8. Before ECT supine position; after ECT side-lying 9. Have patient VOID before giving ECT

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Nursing Diagnosis: 1. Risk for Airway Obstruction/aspiration 2. Risk for Injury 3. Impaired/Altered Cognition/LOC Nursing Intervention 5 S in Seizure 1. Safety (#1 objective) 2. Side-lying (#1 Position) 3. Side rails up 4. Stimulus (no noise & bright lights) 5. Support the head with a pillow AFTER the seizure

FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway. Observe for respiratory problems Remain with client until alert. VS q 5 min until stable. REORIENT: Ttime, place (unit), person (nurse); Reassure regarding confusion and memory loss. Same RN before & after.

B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major depressive episode 1. Bipolar, depressive: Mmost recent or current behavior displaying major depression
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2. Bipolar, manic: Mmost recent or current behavior displaying overactive, agitated behavior 3. Bipolar, mixed: Rrapid intermingling of depressed and manic behavior 4. Cyclothymania: Nnumerous occurrences of abnormally depressed moods over a period of at least 2 years 5. MANIA: Mood that is elevated, expansive, or irritable Manic behavior is a defense against depression since the individual attempts to deny feelings of unworthiness and helplessness. MANIC EPISODE: Neurotransmitter imbalance: * 1. Norepinephrine 2. Serotonin

BEHAVIORS COMMONLY ASSOCIATED WITH MANIA a. Affective: Eelation/ euphoria, lack of shame, lack of guilt, humorous, intolerance of criticism, expansiveness, inflated selfesteem* b. Physiological: Dehydration, inadequate nutrition, needs little sleep, weight loss* c. Cognitive: Ambitiousness, denial of realistic danger, distractibility, grandiosity, flight of ideas, lack of judgment. * d. Behavioral: Aggressiveness, provocativeness, excessive spending, hyperactivity, poor grooming, irritability, argumentative* DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for at least 1 week: 1. Delusion of Grandeur over self-worth, inflated self-esteem RATIONALE: Aa defense to mask feelings of depression & inadequacies 2. Insomnia 3. Flight of ideas 4. Excessive involvement in pleasurable activities without regard for negative consequences 5. Flight of ideas talkative/pressured speech/pressure to keep talking Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject to another.
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6. Hyperactive & Distractibility 8. Easily Agitated 9. Manipulative 10. Increased Metabolism 11. Poor impulse control impulsive 12. Violent/aggressive/hypersexual 13. Pressured speech NURSING DIAGNOSIS: 1. Risk/ Potential for Injury directed to others /or to self 2. Fluid & Electrolytes Imbalances 3. Fluid Volume Deficit

NURSING INTERVENTIONS: 1. Accept client; reject behavior 2. Provide consistent care 3. Set limits of behavior/external controls *One staff to provide controls *Do not leave alone in room when hyperactivity is escalating *Explain restrictions on behavior *Do not encourage performance/jokes *Approach in a calm, collected, non-argumentative manner 4. Distract and redirect energy: Cchoose physical activities using large movements until acute mania subsides (dancing, walking with staff) Meet nutritional needs: Hhigh-calorie FINGER FOODS and fluids to be carried while moving. Prone to become fatigue, so, give finger foods: potato chips, bread, raisin, and sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL BAKERY PRODUCTS!!! Tuna sandwich & apple are appropriate food for bipolar manic
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A Husband of 36 y/o bipolar manic type says, My wife hasnt eaten or slept for days. The RN should place a priority focus on physical condition. Encourage rest: Ssedation PRN, short PM naps 7. Avoid ACTIVITIES that increases attention span such as chess, bingo, scrabble... 8. Avoid CONTACT SPORTS: Bbasketball, gym, strenuous activities & Increase perspiration!! ACCEPTABLE ACTIVITIES: Bbrisk walking, punching bag, raking leaves, tearing newspaper. 9 Productive activities: Ggardening, finger painting, household chores, Activity for Manic Bipolar includes raking leaves (quiet physical, constructive, productive) to increase self-esteem; competitive is not safe. 10. Less environmental stimulus: Nno bright lights, do not touch 11. Encourage OFI: Bbecause of Lithium and increased metabolism 12. Check Lithium intoxication SELECTED SITUATIONS AND INTERVENTIONS: A. Disturbing the Group Session 1. Separate the patient from the group, REMEMBER dont touch the patient Touching the patient may increase AGITATION. 2. Setting of limits matter of fact (#1 Attitude therapy for manipulative patients) Patient in acute manic phase begins to disrobe, appropriate nursing action includes removing patient from group meeting & accompany him to his room B. Aggressive Reaction 1. Decrease environmental stimulation A pt who is pt watching TV suddenly throws the pillows & chair, immediate action is to place pt in seclusion. Staff 1st used a lesser means of control for less success. Shows a documentation that indicates a pts right is being safeguarded during aggressive reactions.
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C. Violent Patients 1. Move to the door fast and call the crisis management team D. Swearing 1. Setting of Limits 2. Give avenues for verbalization/expression vs. Physical violence

MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM For: (Mood disorder specifically Mania (Bipolar Disorder) USES: Elevate mood when client is depressed; dampen mood when client is in manic; used in acute manic, bipolar prophylaxis; ACTS by reducing adrenergic neurotransmitter levels in cerebral tissue through alteration of sodium transport affects a shift in intraneural metabolism of NOREPINEPHRINE Action: hyperactivity and balance or stabilize the mood Effect: 1 wk. CODE: LITH Lithium CO3 Eskalith, Lithane, Lithobid Lithium Citrate Cibalith - S Therapeutic Serum Level: = 0.5-1.5 mEq (local/CGFNS) = 0.6 1.2 mEq (NCLEX) a. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours after the last dose. Long-term: q 2-3 months. Before lithium is begun baseline RENAL, CARDIAC, and THYROID status obtained.

Antidote: 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open angle glaucoma) 2. MANNITOL (Osmitrol) osmotic diuretics Action to urine output, cerebral edema

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3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for severe intoxication 4. . If patient forgets a dose, he may take it if he missed dosing time by 2 hours; if longer than 2 hours, skip the dose and take the next dose. NEVER DOUBLE A DOSE!!!

Nursing Considerations: 1. Before extracting Lithium serum level Lithium fasting 12 hrs check vital signs 2. Avoid diuretics to prevent hyponatremia 3. Avoid strenuous exercise/activities gym works 4. Avoid sauna baths 5. Avoid caffeine because it is a diuretic 6. For hypernatremia AVOID Na CO3 7. Avoid taking soda and/or soda drinks 8. OFI 3 L /day; Na 3mg/day A patient who is talking lithium must be placed in a normal sodium (3 gms.) , high fluid diet (3 L of water). This is done to facilitate excretion of lithium from the body. A. Increase Na = Lithium effect For hypernatremia AVOID Na CO3 Avoid taking soda and/or soda drinks When the lithium level falls below 0.5, the patient will manifest signs and symptoms of mania. B. Decrease Na = Lithium intoxication MORE dangerous!!!! AVOID the 2 dangerous D: diuretics & dehydration Avoid diuretics to prevent hyponatremia Avoid strenuous exercise/activities gym works Avoid sauna baths (EXCESSIVE PERSPIRATION) Avoid caffeine because it is a diuretic Stages in Lithium Intoxication

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I. Early/Initial/Mild: 1.5 mEq - Nausea, vomiting & anorexia - Diarrhea - Gross hand tremors - Abdominal cramps hypocalcemia metabolic alkalosis (Prolong vomiting metabolic acidosis) II. Moderate: 1.6 2.4 mEq Symptoms are 2x the initial signs III. Severe: 2.5 mEq 1. Nnystagmus, tactile, olfactory & visual hallucination 2. POA (Polyuria, Oliguria, Anuria) ARF (Kidney problem) Lithium is nephrotoxic & teratogenic 3. Grand Mal Seizure Cerebral hypoxia LOC COMA death

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PSYCHOSOMATIC / SOMATOFORM DISORDERS A. PSYCHOSOMATIC DISORDERS: Wwithout any organic or REAL physiological OBJECTIVE symptoms. Emotional stress may exacerbate or precipitate an illness. The way an individual reacts to stress depends on his physiological and psychological make-up. Structural changes may take place and pose threat to life. Defense mechanisms include REPRESSION, PROJECTION, CONVERSION and INTROJECTION. Synergistic relationship exists between repressed feelings and overexcited organs. Somatoform disorders result in impaired social, occupational and other areas of functioning. PSYCHOPHYSIOLOGIC DISORDER: with real symptoms!
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Physical symptoms whose etiologies are in part precipitated by psychological factors and may involve any organ system. Cardiovascular: Hypertension, Tachycardia Gastrointestinal: Peptic Ulcer, ulcerative colitis, Colic Respiratory: Asthma, Hyperventilation, Common colds, Hay fever Skin: Blushing, Flushing, Perspiring, Dermatitis Nervous: Chronic fatigue, Migraine headaches, Exhaustion Endocrine: Dysmenorrhea, Hyperthyroidism Musculoskeletal: Cramps Others: Obesity, hyperemesis gravidarum

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NURSING CARE: Holistic or TOTAL physical and emotional Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and the TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS Develop nurse-client relationship: Respect the client and his problems. Help to express feelings, Allow client to feel in control Let client meet dependency needs. 2. Help to work through problems and learn new coping mechanism. TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS 1. CONVERSION DISORDER: Presence of physical symptoms with NO identified physical etiology. CHARACERISTICS: #1 Sign Labelle Indifference a. Can take the form of blindness, deafness, paralysis or any other physical conditions but with no organic basis. b. Client derives primary and secondary gains from the physical symptoms. ASSESS FOR: TWO GAINS IN CONVERSION DISORDER Primary gain. REPRESSION: Keeps internal need or conflict out of awareness. SYMBOLISM: Symptom has symbolic value to client. Secondary gain. (Not connected to the primary gain) Additional advantages: Ssympathy, attention, avoidance. Reinforces maladjusted behavior.

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NURSING INTERVENTION: Dos: Divert attention from symptom; Provide social and recreational activities; Reduce pressure on client; Control environment Donts: Confront client with his illness; Feed into secondary gains through anticipating client needs.

2. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable symptoms and no organic changes. #1 Sign is DOCTOR SHOPPING: Inability to accept reassurance even after exhaustive testing activities as going from doctor to doctor to find cure. ASSESS FOR Preoccupation with body functions or fear of serious disease misinterpretation and exaggeration of physical symptoms Adoption of sick role and invalid life-style; signs of severe regression Lack of interest in environment history of repeated absences from work If the client is MALINGERING: Ddeliberately making up illness to prolong hospitalization; faking illness Nursing Intervention: Show acceptance of the client. Prepare for, assist in complete medical workup to reassure client and rule and medical problems Psychotherapy, family therapy and group therapy: A combination of somatic and behavioral treatment modalities facilities treatment of the disorder. o Meet physical needs giving accurate information and correcting misconception. o Demonstrate friendly, supportive approach but NOT focusing on the illness. o Provide diversionary activities that build self-esteem. o Help client refocus on topics other than the illness. o Assist client understand how he uses illness to avoid dealing with his problems. DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection, Conversion, and Introjection
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DISSOCIATIVE DISORDERS A. DEFINITION: Psychiatric disorder involving disruption in the usually integrated functions of consciousness, identity, memory, or perception of the environment; Client attempts to deal with anxiety by BLOCKING certain areas out of the mind or deeply REPRESSING traumatic events, or by PSYCHOLOGICAL RETREAT from reality; A condition NOT of organic origin and usually occurs as a result of some very painful experience B. ASSESSMENT FINDINGS: AMNESIA: Sselective or generalized and continuous loss of memory FUGUE: Sstate of dissociation involving amnesia and actual PHYSICAL FLIGHT transient disorientation where client is unaware that he has traveled to another location (Client does not remember period of fugue.) DEPERSONALIZATION: Aalteration in perception or experience of self, sense of detachment from self, as if self is NOT REAL DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY): Donated by two or more personalities, each of which controls the behavior while in the consciousness C. NURSING IMPLEMENTATION: Assess what form the dissociative disorder is manifesting and degree of interference in ADL, lifestyle, and interpersonal relations Reduce anxiety-producing stimuli Redirect clients attention away from self; increase socialization / diversional activities Support modalities of treatment: o Abreaction: aAsssisting in the recall of past, painful experiences o Hypnosis; cognitive restructuring o Behavioral therapy o Psychopharmacology: Anti-anxiety, antidepressant Most appropriate intervention for Dissociative Personality Behavior includes encouraging to chart alternative personality. PERSONALITY DISORDERS
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A. DEFINITION: Borderline state of personality characterized by defects in its development or by pathologic trends in its structure; premorbid personality of individuals resembling the compensatory mechanisms associated with the pathologic counterpart.

B. PREDISPOSING FACTORS & CAUSATION 1. Biological predisposition malnutrition, neurologic defects & congenital predisposition 2. Development of maladaptive behavior 3. Freudian fixation

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GENERAL CHARACTERISTICS: 1. Denial 2. Maladaptive behavior inflexible 3. Minor stress poor tolerance mood disturbance 4. in reality 5. Not caused by physiological pattern - Attitude can be changed - Immature - do not adjust to environment 3 CLUSTERS OF PERSONALITY DISORDERS 1. Cluster A Disorders: Odd / Eccentric a. Paranoid b. Schizoid c. Schizotypal 2. Cluster B Disorders: Dramatic / Erratic a. Histrionic b. Narcissistic c. Antisocial d. Borderline 3. Cluster C Disorders: Anxious/ Fearful a. Dependent b. Avoidant c. Passive Aggressive d. Obsessive Compulsive CLUSTER A: ODD / ECCENTRIC A. Paranoid Personality Disorder CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER P) - suspicious, distrustful oral fixation - Loneliness suspicious/mistrust pathologic jealousy, hypersensitive
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#1 DEFENSE MECHANISM: Projection #1 NURSING DIAGNOSIS: Social Isolation #1NURSING CONSIDERATION/INTERVENTIONS: 1. Passive Friendliness no eye contact, mo touch, no laughing/giggling, non whispering 2. Consistency 3. Proxemics: 7 feet away from the patient B. Schizoid Personality Disorder CHARACTERISTICS: - Socially distant, detached, low IQ - introvert, loner, aloof, humorless - avoids close relationships with family, friends, peers - Flat affect indifferent to praise - Functional when works alone; more interested on objects Shy, introverted since childhood but with fair contact with reality Autistic thinking, dreaming, emotional detachment, avoidance of meaningful interpersonal relationships, cold and detached #1 NURSING DIAGNOSIS: Social Isolation\

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C. Schizotypal Personality Disorder - Similar with schizophrenia CHARACTERISTICS: - Odd, eccentric, lowest IQ - Magical thinking, e.g., superstitiousness, telepathy - Ideas of reference or delusion of reference - Cold/aloof limit social contact=social anxiety - Peculiarity in speech but no looseness of association - may develop into schizophrenia or other psychotic disorders - Withdrawn, unattached, odd and eccentric, - Diminished affective (blunted/inappropriate affect) and intellectual skills, vague, over elaborate speech - Frequent part of vagabond or transient groups of society #1 NURSING DIAGNOSIS: Social Isolation CLUSTER B: DRAMATIC/ ERRATIC

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A. Antisocial Personality Disorder


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- 15-40 y.o, mostly in males - History of conduct disorder (6-11 yo) THEORIES: Ggenetic/hereditary Physical/Sexual abuse Low socioeconomic status maladaptive behaviors CHARACTERISTICS: - Impulsive, aggressive, manipulative - Low self-esteem - lack remorse - hates rule/regulations, authority figures - coprolalia (bad words) - Kills, cheats, steals, rapes, destroys - #1 Defense Mechanism: Rrationalization - Underdeveloped superego; lack of guilt, conscience and remorse; unable to learn from experience or punishment - Life-long disturbances that conflict with laws and customs - Unable to postpone gratification, immature, irresponsible - Randomly acting out aggressive egocentric impulses on society; reckless, unlawful, disregard for right of others. - Steals, cheats, lies - Appears charming, intellectual, smooth talker - Antisocial patients have low tolerance to frustration.

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NURSING INTERVENTION/CONSIDERATION: 1. SETTING OF LIMITS matter of fact, voice not high nor low, does not say please. Setting of limits prevent the patient from manipulating the nurse. 2. Consistency is a must regarding rules & regulation. Efficacy of treatment is achieved for an antisocial if the patient is able to respect nurses & other patients boundaries.

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Positive outcome for antisocial personality disorder includes adherence to rule of hospital unit Interventions that can be appreciated by antisocial include exchanging tokens for any privilege B. Borderline Personality Disorder - Mostly in females THEORIES: Ffaulty parent-child relationship; dysfunctional family Trauma; physical/sexual abuse (18 months) low ego Unfulfilled need of intimacy CHARACTERISTICS: - Impulsive, self-destructive, unstable - Self-mutilation & suicidal Therapeutic measure to prevent self-mutilation in borderline includes behavioral contract. The purpose of behavioral contract in borderline is to limit use of unhealthy defense mechanisms - Unpredictable behavior (gambling, shopping, sex, substance abuse) - Disturbance in self-concept: Iidentity - #1 DEFENSE MECHANISM: Ssplitting Youre the only nurse who understands me. This statement is shown in a patient with borderline behavior. - Identity disturbance with chronic feelings of emptiness (Anhedonia) - Marked mood swings and impulsive unpredictable behavior with potential for self-destruction. - Intense, brief, unstable interpersonal relationships with impulsiveness, manipulation, physical fights and temper tantrums A borderline patient indicates an improvement when she state, I ran around the block rather than cutting myself. Borderline personality with a history of cutting her wrist shows an intense & a changeable

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affect during the middle phase of nurse-pt relationship. The patient says, "Youre a smart nurse. I want to be just like you. This statement shows Transference A patient borderline state, Youre a phony. You dont know what happened to me. Best response of the nurse will be, Ill ensure what is necessary will be done to you Intervention for borderline d/o includes setting of limits through saying, The policy of the unit is that, You cant leave in the unit in 1st 24 hrs. C. Histrionic Personality Disorder - More common in women, 2-3 % of the population THEORY: Llacks Electra complex (no father figure) Papas girl

CHARACTERISTICS: - Emotional, dramatic, theatrical - wants to be the center of attention - Manipulative, Sexually seductive or provocative - Exaggeration of emotion, Style of speech is excessively impressionistic - Labile emotion, Positive: Ccreative, imaginative - Extroverted, manipulative, vain with behavior directed toward gaining attention to self; - Emotionally unstable; uses somatic complaints to avoid responsibility D. Narcissistic Personality Disorder - Usually Men - Another: Mmetrosexual CHARACTERISTICS: - Vanity in personal appearance - Exaggerated or grandiose sense of self-importance - Boastful, egotistical, superiority complex
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- preoccupied with fantasies: Ppower, success, beauty - Excessive admirations; envies other, arrogant, lack of empathy -Overblown sense of importance, grandiosity; with strong need for attention and admiration from others CLUSTER C: ANXIOUS / FEARFUL A. Obsessive Compulsive Personality Disorder - More in women - Obsession irresistible thought, Compulsion irresistible action THEORIES: Genetic: Serotonin imbalance Anal fixation strict toilet training Overpowering mother CHARACTERISTICS: - Cardinal Signs: RITUALISTIC - #1 DEFENSE MECHANISM: Undoing, Repression, Symbolization # 1 Ritual: handwashing Other Ritualistic behaviors: 4 Cs: Controlling perfectionism Collects or hoarding Cleaning Checking

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Rigid, over-conscientious, perfectionist, inflexible, cold affect Driven by obsessive concerns Sets high standards for self and others Preoccupied with details, rules and organization STEP TO STEP PRIORITY NURSING DIAGNOSIS: Altered Sleeping Patterns Altered Skin Integrity Ineffective Individual Coping

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PRIORITY NURSING INTERVENTIONS: 1. Give appropriate time to do rituals to decrease anxiety In OCD, intervention includes giving an extra hr to the pt to do the ritual before starting the task. Question most likely to elicit response for treatment of compulsive hand washing includes asking how much has the symptom interfered with your daily activities? 2. Do not abruptly stop rituals 3. Setting of limits avoid manipulative and controlling behaviors 4. TX: Tricyclics antidepressants balance serotonin and norepinephrine Effects: 2-4 wks. Clomipramine (Anaframil) #1 drug of choice for OC Imipramine (Toframil) 2nd drug of choice An oriented group therapy is indicated for OCD B. Dependent Personality Disorder - Most common personality disorder for Acute wife battering syndrome - Co-dependency enabling Statement of pt that indicates ability to care for self after being victim of domestic violence includes a statement like, I have a car key & money hidden outside the house. Battered wife should be referred to shelter Batterers are violent, loving & remorseful (dual personality) Wife batterer has low-self esteem Honeymoon episodes in acute wife battering syndrome showing statement of reconciliation includes, Mama, pls. get these red flowers. I love you & Ill never do it again. CHARACTERISTICS: - Submissive, clinging

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- lacks self-confidence, low self-esteem, helpless, good follower - Lacks self-confidence, helpless when alone, preoccupied with fear of being alone - Fails to make decisions and accept responsibility induces others to take responsibility A pt with Dependent personality who shows ineffective decision making should have setting of limits & make behavioral contract on its daily activities.

C. Avoidant Personality Disorder CHARACTERISTICS: - Shy, timid, inferiority complex - avoid open forum - Over sensitive to rejection/criticism - Social withdrawal = inept - Depression, anxiety, anger are common - Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity when with others -Unwilling to get involved with others and in situations where negative evaluation, rejection and failure are a possibility C. Passive Aggressive Personality Disorder CHARACTERISTICS: - insecure backbiter plastic - loves to procrastinate, cant finish a task - Patients with passive-aggressive personality expresses anger through passivity. #1 Defense Mechanism: Rreaction formation . Goal of nurse in Passive Aggressive Personality includes verbalization of anger when needed Goal of Care for Passive Aggressive includes verbalization of feelings of anger when the need arises.
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COGNITIVE / ORGANIC MENTAL DISORDERS I. COGNITIVE/PSYCHIATRIC DISORDERS With organic etiology With deficits in COGNITION and MEMORY Effects: Cchanges in levels of functioning and disturbed behavior MOST COMMON AREAS OF DIFFICULTY (JOCAM) J Judgment (impaired) O Orientation (confused/disoriented; illusion/hallucination) C Confabulation (filling in memory gaps) A Affect (mood changes, depression, tearful, withdrawn) M- Memory (Impaired especially for names and recent events compensated by confabulation and circumstantiality)

DELIRIUM VERSUS DEMENTIA

Delirium Acute in onset onset Reversible #1 sign: Clouding of consciousness memory Or grand mal / tonic-clonic seizure

Dementia Chronic / Gradual in irreversible #1 Sign: Progressive Loss

Causes: Hyperthermia, sepsis such as (idiopathic) Encephalitis, meningitis, drug induced Withdrawal (alcohol & cocaine withdrawal) SYMPTOMS OF DELIRIUM

Causes: Uunknown

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* Difficulty with attention * Easily distractible * Disoriented * May have sensory disturbances such as illusions, Misinterpretations or hallucinations * Can have sleep wake cycle disturbances * Changes in psychomotor activity * May experience anxiety, fear, irritability, euphoria,

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TYPES OF DEMENTIA Picks Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes) and reactive gliosis. Vascular/Multi-infarct Dementia: Ppatchy cognitive deterioration (dependent on infarct site) appearing within 1 years of vascular injury; common in men and earlier in onset. Huntingtons Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea, gait disturbance, slurred speech) & cognitive changes (dementia) Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA); rapidly progressive from vague somatic complaints to ataxia, dementia then death. Parkinsons Disease:
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Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling & resting), bradykinesia, cogwheel rigidity, shuffling gait, masklike fascies. Progresses to depression & dementia, treated with L-dopa Nursing care for the patient with dementia is geared towards maintaining existing functions by minimizing regression. Place an alarm signal to know that the pt is attempting to exit in a dementia client who used to wander away from acute facility. ALZHEIMERS DISEASE Degenerative disease of the central nervous system characterized by premature senile retardation. Degenerative disorder of the cerebral cortex. The etiology of Alzheimers disease is unknown The most common non- traumatic cause of dementia is Alzheimers disease at 65, 10% of the population has Alzheimers; by 85, the percentage increases to half. Multi-infarct dementia is the second most common cause of non traumatic dementia. NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-65; may die within 2 yrs or 8-10 yrs if with total care. The main pathology is the of presence of senile plaques that destroys neurons leading to decreased acetylcholine. The primary need of a patient with Alzheimers is Reorientation.

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4 CARDINAL SIGNS OF ALZHEIMERS 1. Agnosia sensoryinability to recognize objects/subjects Patient with agnosia is unable to recognize persons. 1st to forget: Tthe name of an object 2nd to forget is the function of an object 2. Apraxia sensory-inability for purposeful movt. ex. Tremors 3. Amnesia 1st amnesia to appear: Aanterograde amnesia recent memory

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2 amnesia to appear: Retrograde past Tx: Reminiscing Group Therapy 4. Aphasia sensory-inability for speech and communication Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C. Townsend Exact cause unknown but several hypothesis were introduced; (pg 342-343) 1) Acetylcholine Alteration: Ddecrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive process. 2) Accumulation of Aluminum: Sstudies show that aluminum accumulates in damaged areas of the brain. 3) Alterations in the Immune System: Aantibodies are being produced in the brain which causes a reaction against self it is called autoimmune. 4) Head Trauma: Head injuries 5) Genetic Factor: Pattern of inheritance

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THREE STAGES OF ALZHEIMERS Early stage (Forgetfulness Stage: Mild) The first symptom of Alzheimers disease is Progressive memory loss. This is followed by disorientation, personality changes, language difficulty, and other symptoms & dementia. The patient can compensate for the memory loss but the family may notice personality changes and mood swing. Recent memory is affected including the ability to learn new information. Managing daily living activities becomes progressively more difficult. The patient may notice difficulty balancing his checkbook and may forget where he put things. Forgetfulness: loose things; forget names, short-term memory loss, and the individual is aware of the intellectual decline. Early Confusion: Symptoms of confusion begins and concentration may be interrupted. Individual may forget major event in personal history such as birthday of his/her child: experience declining activity to perform task; individual may deny memory loss. Findings that are observed in the early stages of Alzheimers disease are inappropriate affect, disorientation to time, paranoia, memory loss, and an impaired judgment.
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* Response of nursing assistant to an Alzheimers patient that Needs Further Teaching includes a statement like, How many glasses of water did you drink today? - Anterograde amnesia. Middle stage (Wandering Stage/Sundown syndrome) The patient is increasingly disoriented and completely unable to learn and recall new information. He may wander or become agitated or physically aggressive. He may have bladder incontinence and may require assistance with activities of daily living. Individual may be unable to recall major life events even the name of spouse. Disorientation in the surroundings is common and the person may be unable to recall the day, season, and year. Sleeping becomes a problem. Symptoms worsen in the evening known as SUNDOWNING. Late stage (Kluver Bucy like Syndrome) The patient may be unable to walk and is completely dependent on caregivers. Hes totally incontinent of bowel and bladder. He may even be unable to swallow and is at risk for aspiration. Hes unable to speak intelligibly. In the late stages of Alzheimers disease it is better to go along with the patients reality rath er than confront him with logical reasoning. Asking close ended simple questions that relate to his reality is non-threatening and calming. Note that the nurses response in a way that is congruent is the main concern. The individual may not recognize family members. There may be problems of immobility.

Nursing Diagnosis: Risk for trauma Nursing Intervention: 1) Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS NEEDED to decrease chances of disorientation & confusion. In milieu therapy, patients plan and lead activities rather than the staff. Millieu therapy involves scientific manipulation of the environment that can influence
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improvement patients behavior 2) Store frequently used items within reach. 3) Keep bed in unelevated position with soft padding if client has history of seizure and keep the rails up. A confused Alzheimers patient who gets out of bed several times must be provided with a safe environment like placing a hand rails for the patient to hold. Bed of confused Alzheimers patient must always have its side rails up. 4) Assign room near nurses station. 5) Assist patient with ambulation. 6) Keep dim light on at night. Decrease environmental stimulus. 7) If patient is a smoker, stay with him/her at all times. 8) Frequently orient patient to time, place and situation. 9) If patient is prone to wander, provide an area in which the client is safe to wander. 10. Family counseling about Alzheimers disease includes checking that pt is wearing ID bracelet when going out at all times 11. Soft restrain may be required if the client is disoriented and hyperactive as ordered by the physician. 12. Provision of simple, structured environment, choices Consistency and ROUTINE in care to increase security; Brief, frequent contacts; reinforce reality-oriented comments Ample time and patience to allow client to talk / complete tasks using associative patterns to improve recall: simplicity, focusing, repeating, summarizing. Allow REMINISCING of past life / exploits / achievements. Reminiscing helps lessen the patients loneliness. 13. Wear the Medical Alert Bracelet (name, Address, Tel #, Diagnosis, Medication)

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14. Avoid afternoon naps, avoid caffeine, TV & radio remote 15. REMEMBER THE 3 Cs for Alzheimers to DECREASE DISORIENTATION: Color, Calendar, Clock

Nursing Diagnosis: Altered thought process Nursing intervention: 1) Frequently orient the patient to reality. Sensory stimulation for elders helps to increase pts arousal 2) Keep explanation simple and use face-to-face interaction. Speak slowly and do not shout. In caring for elderly w/ Alzheimers use short & simple words & face him while you are talking. 3) Discourage rumination of delusional thinking. Talk about real people and real events. 4) Monitor for medication side effects. 5) Use soft tone, simple sentences, and a slow, calm manner when speaking to a person with Alzheimers disease. If he doesnt understand you, repeat yourself using the same words. Your nonverbal communication is more important than your actual spoken message. Dont a hurried tone, which will make the patient feel stressed. Move slowly and maintain eye contact.

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Nursing Diagnosis: Self-care deficit Nursing Intervention: 1) Identify self-care deficit and provide assistance. Urinary incontinence in patient with Alzheimers can be controlled by decreasing fluid intake at night time 2) Allow plenty of time for the patient to perform task. 3) Provide guidance and support for independent actions by talking the patient through the task. 4) Provide structure schedule of activities that does not change from day to day. 5) ADLs should follow home routine as closely as possible. 6) Provide clients nutritional needs, safety and security. . 7. Give foods high in carbohydrates to an Alzheimers who refuses to eat his meal In an Alzheimers caregiver class, the nurse tells the student that the reason why pts do not take a bath is that they cant remember anymore if they have taken the bath already.

Screening Test: MS Brunner and Suddarth (pg 160) 1) Electroencephalography 2) Computed tomography 3) Magnetic Resonance Imaging Confirmative Test: MS Brunner and Suddarth (pg 160) Cerebral biopsy after death. Complication: MS Brunner and Suddarth (pg 158) 1) Infection 2) Malnutrition

Best Drug: Anticholinesterase:I increases ACH (acetylcholine) levels MS Brunner and Suddarth (pg 160) Tacrine hydrochloride (Cognex) Donezepil (Aricept)
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Rivastigmine (Exelon)

DRUG STUDY: No cure or definitive treatment exists for Alzheimers disease. However, three drugs, tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved by the Food and Drug Administration to improve cognitive function in patients with mild to moderate Alzheimers disease. Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus maintaining memory skills for a period of time. SUMMARIZED DRUGS USED TO TREAT DEMENTIA

NAME

DOSAGE RANGE AND ROUTE

NURSING CONSIIDERATION

Tacrine (Cognex)

40 160 mg orally per Monitor liver enzymes day divided into 4 doses for hepatotoxic effects. Monitor for flu like symptoms. 5 10 mg orally per day

Donepezil (Aricept)

Monitor for nausea, diarrhea, and insomnia. Test stools periodically for GI bleeding.

Rivastigmine (Exelon)

Monitor for nausea, 3 12 mg orally per vomiting, abdominal day divided into 2 doses pain, and loss of appetite.
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Galantamine (Reminyl) 16 32 mg orally per


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Monitor for nausea,


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day divided into 2 doses vomiting, loss of appetite, dizziness, and syncope.

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BEST HERBAL DRUG FOR ALZHEIMERS: Enhancing memory with ginkgo biloba Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow memory loss in people with Alzheimers disease, Research has shown that ginkgo produces arterial, venous, and capillary dilation, leading to improved tissue perfusion and blood flow. Adverse effects are uncommon but may include GI upset or using anticoagulants.

EATING DISORDERS #1 CAUSE: Unknown #1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality THEORIES OF CAUSATION: 1. Behavioral: Aattention-seeking by rejecting foods; manipulation to gratify needs 2. Family interaction: Aambivalent feelings towards mother; overprotection, rigidity, lack of personal boundaries and independence; use of anorexia to avoid interpersonal conflicts. The issue of CONTROL is a central one for the client with anorexia nervosa. It is believed that symptoms are caused by stressor that the adolescent perceives as a loss of control in some aspect of her life. Controlling intake and weight gain is a way the client establishes a sense of control over her life. 3. Psychoanalytic: Rregression to oral and anal developmental stage to avoid adolescent sexuality and independence 4. Medical: Ggenetic predisposition, increased catecholamines, hypothalamus dysfunction ANOREXIA - Amenorrhea lanugo BULIMIA - Binge/purge syndrome Binge eating: Eating
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increased
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amounts of high calorie food in a short period of time. -2 binge-eating episodes or more per week for 3 months - 15-20% ideal weight - fluctuation of body weight Defective defense mechanism: Denial Poor to fair prognosis There is ACCEPTANCE - good prognosis acceptance - Bulimic patients are usually aware of their abnormal behavior.

CHARACTERISTICS - vegetarian - All are females - Adolescent 11-17 yo - hoards/collects food - strenuous exercise - introvert - Patients with eating disorders are usually high achievers, perfectionist and preoccupied with food.

CHARACTERISTICS - carbohydrate, caloric fast foods - 4 % are Boys - young adults - loves to cook -abuses laxatives/enema - extrovert

OTHERS: Refusal to take meals dramatic weight loss Anorexic patients usually suppress their appetite, which makes it difficult for the nurse to convince them to eat. Resistance to treatment; difficulty accepting nurturance & caring Feelings of loneliness and isolation Hypotension, bradycardia, hypothermia Secondary sexual organ atrophy; Complications: amenorrhea - esophageal varices
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Reduced metabolism, reduced hormonal - dental carries functioning; hypoglycemia; electrolyte - callous finger - chipmunk face imbalance Hyperactivity; Constipation; Leukopenia Skin problem: Hyperkeratosis (overgrowth of horny layer of STEP BY STEP NURSING epidermis) DIAGNOSIS: 1. F/E imbalance 2. Fluid volume deficit hypovolemic shock Complications: #1 Cause of death: cardiac 3.Altered Nutrition less than body dysrrhythmia --. Hypokalemia ECG requirement ST segment depression & Prominent U wave

STEP BY STEP NURSING DIAGNOSIS: 1. F/E imbalance 2. Fluid volume deficit hypovolemic shock 3. Altered Nutrition less than body requirement 4. Altered Body Image Change of body image causes difficulty in self-esteem. Long term treatment for anorexia/bulimia includes outpatient family therapy sense of control over herself is a positive outcome in eating disorder.

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NURSING INTERVENTION FOR EATING DISORDERS 1. DIETARY THERAPY restoration and stabilization of nutritional and fluid balance a. Feedings: Ooral, IV or tubes; monitor hydration and electrolytes An anorexic patient with high urine specific gravity must be encouraged to have an increase fluid intake b. Caring and nurturance when possible c. Provide education 1) on growth & development and normal nutrition 2) Limit setting: Bbased on weight gain or loss, grant or restrict privileges; use behavioral contract to enforce limits 2. ASSESS AND EVALUATE: Weight and % of normal body weight loss; weighing 3x a week: Ssame time, clothing and weighing scale. Limit activity based on weight gain: For wt. Loss complete bed rest; gain less than 100 g- with bathroom privileges; more than 200 g- may ambulate in the hospital Eating patterns: Aamount, type of foods, time and place of eating, whether food is forced or followed by vomiting; Provide surveillance 30 min. to 1 hr after meals Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient from inducing vomiting. Presence of anemia, hypotension, bradycardia, amenorrhea Interpersonal relationships 3. PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP INTERNAL CONTROL reduces need to control by self-starvation. 4. Help client accept eating problem and set realistic, attainable short-term goals 5. Provide support is developing better outlets for emotional expression; Encourage outside interests not related to food 6. Provide teaching on therapeutic diet: Bbalanced, calories restriction to effect WEIGHT GAIN (1-2 pound per week) 7. Offer PRAISE for progress; accept lapses (behavior modification) 8. Instruct and support in behavioral modification program : 1) Control speed of eating chewing food well; 2) Self monitoring w/ food diary; & 3) Praise/reinforce compliance Best discharge plan for anorexic teen includes attending a support group

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DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE SUBSTANCE ABUSE TERMS AND DEFINITTIONS TERMS Psychoactive substance DEFINITIONS
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A substance that affects a persons mood or behavior

Substance abuse

Continued use of a psychoactive substance despite the occurrence of physical, psychological, social, or occupational problems

Substance dependence

A range of physiologic, behavioral, and cognitive symptoms indicating that a person persists in using the substance, ignoring serious substance-related problems The bodys physical adaptation to a drug, whereby withdrawal symptoms occur if the drug is not

Physiologic dependence
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used

Psychological dependence The emotional need or craving for a drug either for its effect or to prevent the occurrence of withdrawal symptoms

Addiction

Polysubstance abuse

A compulsion, loss of control, and progressive pattern of drug use; characterized by behavioral changes, impaired thinking, unkept promises to stop usage, obsession with the drug, neglect of personal needs, decreased tolerance, and physiologic deterioration

Concurrent use of multiple drugs Intoxication

Overdose

An altered physiologic state resulting from the use of a psychoactive drug

Tolerance

Accidental or deliberate consumption of a drug in a dose larger than is ordinarily used, resulting in a serious toxic reaction or death
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Tolerance is the need for the


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Cross-tolerance

increasing amount of a substance to produce its desired effect. It also refers to the decreasing effect of the drug.

Predisposition

A state whereby the effect of a drug is decreased and greater amounts are required to achieve the desired effect because the person has become tolerant to a similar drug

Potentiation Any factor that increases the likelihood of an event occurring Drug misuse The ability of one drug to increase the activity of another drug when taken at the same time

Dual diagnosis

Any use of a drug that deviates from medical or socially acceptable use

Blackout The coexistence of a major psychiatric illness and a psychoactive substance abuse disorder Withdrawal An acute situation in which a person experiences a period of memory loss for actions as a
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Detoxification

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direct result of using drugs or alcohol

Toxic dose

Discontinuation of a substance by a person who is dependent on it

Recidivism

The process of withdrawing a person from an addictive substance in a safe manner

The amount of a drug that produces a poisonous effect Recovery The tendency to relapse into a former pattern of substance use and associated behaviors Sobriety

Abstinence

The return to a normal state of health, whereby the person does not engage in problematic behavior and continues to meet lifes challenges and personal goals

Complete abstinence from drugs while developing a satisfactory lifestyle

Voluntarily refraining from activities or the use of substances that cause problems in the physiologic, psychological, social,
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intellectual, and spiritual arenas of a persons life

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A. ASSESSMENT FINDINGS History. Academic or job failures, marital failures, stealing to support habit, personality change, violent acting out Physical Examination: Mmalnutrition; abdominal cramps; diaphoresis, yawning, lacrimation, rhinorrhea 10 hours after the last opiate injection; needle marks on arms along path of a vein (wearing of long- sleeves); nasal discharge with nasal septum perforation (cocaine) Social: Inability to maintain ADL and fulfill role responsibilities and obligations B. NURSING DIAGNOSES, POTENTIAL: Altered health maintenance/nutrition related to chemical dependence; lack of interest in food High Risk for Violence: Ddirected toward self or others related to feelings of suspicion or distrust; intake of mind-altering substances; misinterpretation of stimuli Defensive Coping related to denial of problem; projection of responsibility or blame; rationalization of failures NON-ALCOHOLIC ABUSED SUBSTANCES DRUG OPIATE or SX OF ABUSE/ SX OF TREATMENT INTOXICATION WITHDRAWAL Euphoria Chills and Naloxone

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Anxiety NARCOTICS: Sadness A CNS Insomnia depressant can cause decreased blood pressure, pulse, respiration, and temperature. 1. Demerol 2. Morphine 3. Codeine 4. Nalbuphine

PERSPIRATION Tremors Narcotic Withdrawal causes muscle ache, rhinorrhea, anxiety 1st 12-72 hrs: -sleep disturbances, piloerection, irritability, tremors, weakness, diarrhea, muscle spasm (legs), abdominal pain, VS changes, decreased self-esteem, depression

(NARCAN) the #1 antidote for Opioids or Narcotic intoxication METHADONE for Heroin Withdrawal :

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HEROIN- (Horse, smack, junk, Smack, ,Horse and Fine China)

Marked respiratory depression PinpointPupils , Hyperpyrexia Ventricular dysrhythmia

Lacrimation (Watery eyes) RUNNY NOSE YAWNING BP Dilated pupils Cramps Muscle SPASM Nausea,
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VOMITING Panic, diaphoresis, and weight loss/anorexia ANXIOLYTICS: Minor tranquilizers Valium Librium Barbiturates(Downes, rainbows, pink ladies) Phenobarbital Nembutal Slurred speech Respiratory depression BP and PR Ataxia/ impaired coordination Drowsiness Seizures, Coma Memory Fatigue Anxiety Depression BP and PR Tachycardia Tremors Convulsions Delirium Hallucinations Anxiety Insomnia Depression Fatigue Apathy Disorientation Irritability Altered sleep Sodium bicarbonate excretion Activated charcoal, gastric lavage

STIMULANTS (Upper, meth, speed, pep, pills, crystal, Ice, Uppers, Crank Amphetamines Dexedrine Methamphetamine

Euphoria Agitation BP, PR, RP, Temp Hyperactivity, dilated pupils, Grandiosity Hypervigilance, Euphoria, Appetite suppression, Personality changes, Antisocial behavior

Activated charcoal, use gastric lavage

Cocaine (Oral, Injected, Inhaled) Coke Crack Snow Blow Lady Powder

Nasal septum perforation Irritability, Seizure Coma, Insomnia, Dilated pupils

Cocaine is characterized by, vivid dreams and hypersomnia or insomnia and psychomotor agitation. Psychosis similar to paranoid schizophrenia

Cocaine use leads to dopamine deficiency. Amino acid therapy is utilized to facilitate restoration of depleted neurotransmitters.
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Hallucinogens: LSD (acid) (PCP :Oral, Injected, Inhaled) Angel dust, Hog, rocket fuel)

Cannabis Derivatives: Marijuana (mary jane, joint, grass, weed, Pot, Hash, Weed)

Hallucination Incoherence confusion Dilated pupils BP, Temp Delirium, Mania, Agitation Convulsions Coma #1 sign RED EYES (irritated conjunctiva) Fatigue Conjunctival Congestion appetite Euphoria Relaxed inhibition Dilated pupils Psychosis

None

Small doses of Valium

Hyperactivity Insomnia Dry mouth Sexual arousal Visual hallucinations

Most effects wear off in 5-8 hr talk down client

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Another word for alcohol is Booze Brew GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION 3 As = Alcohol Withdrawal Aversion Therapy (Punishment) Antabuse (Disulfiram) = no effect unless mixed with alcohol Action: Iinhibit Antabuse effect Acetaldehyde dehydrogenase > Dosage: Acute phase = 500 mg in 1st 2 wks. Maintenance Phase = 250 mg & >Prohibited Household items with alcohol: mouthwash, cough syrup/elixir, vinegar, fruitcake, shaving cream, astringent, and toner, acetone/nail polish
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Cough medicines and other over-the-counter medicines are alcohol-based and may cause antabuse reaction when it is combined with antabuse. Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems.

Effect of Antabuse with Alcohol 1. Nausea & Vomiting 2. Diarrhea 3. Intense headache 4. Abdominal cramps > Short term objective for an alcoholic: Tto stop/cut denial Long term objective: Abstinence (similar with STD/HIV/AIDS) > # 1 group therapy for Alcoholics (12 step recovery program AA (Alcoholic Anonymous) for victims of alcoholics: AL-ANON for alcoholic teens: ALATEEN Correct response of an RN to alcoholic patient who says, I dont want to attend group meeting, I dont need their alcoholic advice. Is a statement like, The group activity may not seem helpful to you but you can help them.

> Screening Questions for alcohol abuse: 1. When was the last time you have taken alcohol? 2. How much alcohol have you taken for the last 24-48 hrs? In a detoxification unit, the nurse asks the pt when was the last time he drink alcohol to determine the onset of alcohol withdrawal syndrome. Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal period.

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Statement of a pt who is alcoholic and undergoing detoxification saying, I can quit whenever I want. shows denial

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HERE HERE!!!!!
CAGE SCREENING QUESTION FOR AN ALCOHOLIC C cut down alcohol (Do you need to cut down alcohol?) A annoyed (Are you annoyed when someone will ask you Are you an alcoholic?) G guilty (Are you guilty of taking too much alcohol?) E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the after effects of alcohol? 3 Stages of Alcohol Intoxication I. Alcohol Serum Level = 0.04 -0.05% > unsteady gait > social & sexual inhibition II. ASL = 0.08-0.1 or 100 mg/dl > slurring of speech > Fruity odor similar to ketoacidosis > Legal intoxication III. ASL = 0.15-0.2 severe alcohol intoxication > 4 Common Complications with History of Alcoholism 1. Liver Cirrhosis 2. Gastritis inflammation 3. Pancreatitis
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4. Wernickes Korsakoffs peripheral neuritis lack of Vit. B1 (thiamine) (Sx: Ttingling sensation/numbness of extremities: Aavoid electric blankets!) Wernickes psychosis is due to thiamine deficiency. Confabulation or making up of stories is one of the initial manifestations of Korsakoffs syndrome. Two categories of Wernickes Korsakoffs: A. Wernickes Aphasia / Receptive Aphasia: Pproblems in interpretation (temporal lobe) B. Korsakoffs Psychosis irreversible (the best drug is Risperidone (Risperdal): Iit has Decrease extrapyramidal symptoms (EPS) 4 Stages of Alcohol Withdrawal

I. Early/Initial Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation & nervousness Symptoms of alcohol withdrawal is observed when the cup rattles to the side when the patient stirs his coffee II. Hallucination #1 hallucination of Alcohol withdrawal is TACTILE Nursing diagnosis for patient with delirium tremens who says, There are bugs in my bed crawling over me is Altered Thought Process 2. Visual hallucination Intervention: > Use lampshade to shadow (illusions) Leaving a light on the patients room will decrease visual hallucinations, which frequently occur in alcohol withdrawal syndromes. Shadow stimulates hallucination dont leave the patient (Offering of self) Assigning a staff to the patient promotes safety especially during withdrawal episodes.
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III. Pre-seizure/RUM FITS Impending signs of Seizure 1. Epigastric pain (early sign in eclampsia) 2. High pitch cry/projectile 3. Eye pain/periorbital pain (scotomas) usually in eclampsia 4. Headache & Aura- ICP 5. Restlessness cerebral hypoxia = 02 & glucose IV. Delirium Tremens Active Seizure = Grand mal/Tonic-Clonic Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated vital signs. Observation indicating a need to be included during endorsement to next shift in an alcoholic patient in the ER include observations of becoming fearful (delirium tremens)

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DRUGS CAUSING DELIRIUM Anticonvulsants Anticholinergics Antidepressants Antihistamines Antipsychotics Aspirin Barbiturates Benzodiazepines Cardiac glycosides Cimetidine (Tagamet) Hypoglycemic agents Insulin Narcotics Propranolol (Inderal) Reserpine Thiazide diuretics

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MOST COMMON CAUSES OF DELERIUM

Physiologic or metabolic

Hypoxemia, electrolytes disturbances, renal or hepatic failure, hypo- or hyperglycemia, dehydration, sleep deprivation, thyroid or glucocorticoid disturbances, thiamine or vitamin B12 deficiency, vitamin C, niacin, or protein deficiency, cardiovascular shock, brain tumor, head injury, and exposure to gasoline, paint solvents, insecticides, and related substances

Infection Systemic: Ssepsis, urinary tract infection, pneumonia Cerebral: Mmeningitis, encephalitis, HIV, syphilis Intoxication: Aanticholinergics, lithium, alcohol, sedatives, and hypnotics Withdrawal: Aalcohol, sedatives, and hypnotics Reactions to anesthesia, prescription medication or illicit (street) drugs

Drug-related

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COMMONLY USED ANTICONVULSANTS 1. Valium (Diazepam) best drug for delirium tremens 2. Librium (Clordiazepoxide)
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Positive) outcome of Librium in alcoholic depressed woman includes an observation that client can pick an object on floor w/ smooth coordination Formatted: Font: 14 pt 3. Klonopin (Clonazepam) Formatted: Font: 14 pt 4. Phenytoin (Dilantin) best anticonvulsant for children Formatted: Font: 14 pt SE: Ggingival hyperplasia & red orange urine Formatted: Font: 14 pt Intervention: Mmassage the gums & use soft bristle toothbrush Adverse Effect: Blood dyscrasia- thrombocytopenia S/SX: Bbleeding of theFormatted: gums Font: 14 pt, Portuguese (Brazil) Formatted: Font: 14 pt Lab test: Pplatelet count = 150,000-400,000; if 100,000active bleeding Special Considerations: The only COMPATIBLE I.V. Solution for Phenytoin (dilantin) is NSS (Normal Saline Solution) 5. Carbamazepine (Tegretol): Anticonvulsant trigeminal neuralgia (tic douloureux) A/E: Agranulocytosis/neutropenia S/Sx: Ssore throat Neutrophils 54-56 % 6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg. Adverse Reaction: Hepatotoxic (assess SGPT or ALT) 7. Ethosuccimide (zarontin) Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid help decrease withdrawal symptoms.
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GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE A. Maintain airway: Iintubation (keep airway on hand), suction B. Start IV line C. Monitoring: BP, respiration, pulse, temperature, LOC D. Prevent and control seizures; Keep in calm, quiet environment E. Check for trauma, protect from injury A pt taking phencyclidine (PCP), shouts & walks back & forth, appropriate nursing intervention includes seclusion, staying w/ the pt, and decreasing stimuli. F. Administer ordered drugs; Detoxify / treat overdose-

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NALOXONE (NARCAN) Pure antagonist to narcotics-induces withdrawal and stimulates respiration; DRUG OF CHOICE when in doubt the substance used because NALOPHINE (NALLIN), a partial antagonist to narcotics, will respiratory depression if barbiturates have also been used METHADONE drug substitute used for acute withdrawal and long-term maintenance; changes an illegal to a legal drug, which is administered under supervision. Antidepressants block the high from stimulant abuse G. Nutrition: Hhigh-calorie, high-protein, high-vitamin

SEXUAL DISORDERS / DYSFUNCTION A. SEXUAL DISORDER: Ddeviations in sexual behavior; sexual behaviors that are directed toward anything other than consenting adults or are performed under unusual circumstances and are considered abnormal B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the pain to self or partner, or children and other nonconsenting individuals. 1. EXHIBITIONISM: Sexual gratification from exposing genitalia 2. FETISHISM: Sexual gratification from an inanimate object (usually clothing material) substituted for the genitals 3. FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting person (usually in crowds, public transportation) 4. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the sexual act or substitute for it 5. PEDOPHILIA: Sexual gratification from children 6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an accompaniment of the sexual act or a substitute for it 7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex 8. VOYEURISM: Sexual gratification from watching the sexual play / act of others 9. ZOOPHILIA: Sexual gratification from animals C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or interference with any of the phases of the sexual responses which may be due to psychogenic factors alone or psychogenic and biologic combined. D. NURSING DIAGNOSES
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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1. 2. 3. 4.

Anxiety related to threat to security and fear of discovery Anxiety related to conflict between sexual desires social norms Sexual dysfunction related to actual or perceived sexual limitations Sexual dysfunction related to inability to achieve sexual satisfaction without the use of paraphilic behaviors 5. Potential for infection related to frequent changes in sexual partners or sadistic or masochistic acts 6. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors

E. GENERAL PRINCIPLES OF CARE 1. Acceptance NOT of the behavior but of the client who is in emotional pain 2. Protection of the client from others 3. Setting limits on the sexual acting out 4. Supporting of self-esteem: Aavoidance of punitive remarks or responses 5. Provision of diversional activities

PERVASIVE DEVELOPMENTAL DISORDERS CODE: ACA Autism, Conduct Disorder, Attention Deficit Hyperactive Disorder (ADHD), AUSTITIC DISORDER
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A. A type of developmental disorder for an unknown; probable underlying problem: failure to develop satisfactory relationships with significant adults - mostly males - talented in music or math - # 1 screening test DDST (Denver Developmental Screening Test) - Autism is usually diagnosed during the toddler stage. CHARACTERISTICS: 1. Blank stare 2. Rrepetitive movement: head banging padded room/helmet 3. Llikes to follow bright moving objects 4. Ccatatonic 5. Ttemper tantrums 6. Cclings to inanimate objects B. ASSESSMENT FINDINGS:
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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1. Disturbance in sense of self-identity, in ego system formation: Iinability to distinguish between self and reality / environment speaks of self in the third person 2. Withdrawal from reality. 3. Lacks meaningful relationship with outside world; turns to inanimate objects and self-centered activities for security 4. Personality alteration adaptive, inhibitory, steering mechanisms due to profound interference in intellect 5. SEVERE AUTISM Severe apathy, Association looseness, Autistic thinking, Poor grasp of reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor intellectual functioning C. NURSING DIAGNOSIS: Potential for Injury D. NURSING IMPLEMENTATION: 1. Provide consistent, routine ADL in familiar environment 2. Set consistent and firm limits for his behavior 3. Make physical contact on a regular basis. Accept the clients need to push but still maintain regular contact. 4. Prevent acts of self-destructive behavior 5. Provide appropriate therapy: Removal from home, if necessary; consistent loving home care is still favored over hospitalization; consistent care giver; never leave alone; and always provide safety. Psychotherapy: Pplay, group, individual therapy Primary treatment goal to facilitate the recovery of an autistic child should include playing with blocks not with balls . Occupational Therapy #1 behavior modification #2 Behavior modification in an autistic child enables the nurse to modify the childs maladaptive behavior. Pharmacology: Tranquilizers and amphetamines to reduce symptoms Caring autistic children requires specialized skills. ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) A. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and characterized by hyperactivity and inattentiveness THEORIES: Norepinephrine, Serotonin

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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PRO Review Soultions and Tutorial Diagnostics 4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

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- #1 Screening Test DDST CHARACTERISTICS: 1. Hyperactive could not sit and stay in 15 minutes 2. metabolism fatigue 3. handwriting not legible 4. Easily agitated by noise & color (orange/yellow) B. ASSESSMENT 1. Severe inattentiveness with or without hyperactivity 2. Short attention span 3. Excessive impulsiveness 4. Squirming and fidgeting 5. Hyperactive could not sit and stay in 15 minutes 2. metabolism fatigue 3. handwriting not legible 4. Easily agitated by noise & color (orange/yellow) C. NURISNG IMPLEMENTATION: 1. Set realistic, attainable goals 2. Provide firm, consistent discipline with opportunities to experience satisfaction and success 3. Provide a structured environment With a balance of energy expenditure and quiet time With learning experience utilizing childs ability With exercise in perceptual-motor coordination With LESS STIMULATION The priority needs of the child with ADHD are safety and provision of inadequate nutrition. Catching attention of a child with ADD includes getting him to look at his mom & give him simple directions. 4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate

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5. #1 Therapy: Occupational Therapy using behavior modification 2. DIET: caloric content finger foods 3. Vitamin B Complex appetite

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4. Do not mix Caffeinated food/drinks with ACA/alcohol 5. Tx: 1. RITALIN (Methylphenidate: BEST GIVEN AFTER BREAKFAST) Always with meals Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of appetite. Psychostimulant to increase attention span 2. Dextroamphetamine (Dexedrine) 3. Pemoline (Cylert) very hepatotoxic!!! 4. Stratera ( Atomoxetine) newest psychostimulant!! Contraindication: Ddo not give below 6 yo hepatotoxic SGPT Stratera, a drug for ADD/ADHD enhances catecholamine effect. Statement like, My son is able to accomplish his task better, indicates efficacy of the drug.

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CHILD ABUSE A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse B. CAUSE: Exact-unknown; Present in all socioeconomic levels C. ASSESSMENT: Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST on admission of a toddler is a sign of abuse.) Inconsistency of declaration of the type, location, cause of injury, discovery of undeclared / unreported fractures Malnutrition / failure to thrive / emotional neglect Sexual abuse signs: Ggenital bruises, lacerations; STDs History: Parents who were abused as kids Other characteristics of abusive parents: 1) Tend to be young, immature, dependent; 20 Low in self- esteem 3) Lacks identity 4) Expect child to provide them with love and care (PERSONAL ROLE THEORY of causation) 5) With incorrect concept of what the child is, and can do 6) With inadequate resources and support system Abusive parents usually have low-self-esteem and has little social involvement. Child abuse is common in the lower socio-economic class. The interaction between the abuse child and a mother provides a clue to the kind of relationship that this child has with his mother.
by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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In working with the mother of abused child, therapeutic use of self requires self awareness initially, therefore the nurse has to deal with her feelings first. Attendance to a parenting class is a step towards learning parenting skills, which are lacking in abusive parents.

D. POTENTIAL NURSING DIAGNOSES 1) Impaired Skin Integrity 2) Infective Family Coping E. NURSING IMPLEMENTATION FIRST: Meet physical needs; treat injuries MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES; TAKE PICTURES) Notify the legal authorities about reports of a battered 7 y/o girl is part of the responsibilities of an RN EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings; NONJUDGMENTAL ATTITUDE toward parents ROLE MODELING for parents who are encouraged to care for child DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion
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POSSIBLE INDICATORS OF ELDER ABUSE Physical abuse indicators Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations Reluctance to seek medical treatment for injuries, or denial of their existence Disorientation or grogginess indicating misuse of medications Fear or edginess in the presence of family member or caregiver Psychological or Emotional abuse indicators Helplessness Hesitance to talk openly Anger or agitation Withdrawal or depression

Financial abuse indicators Unusual or inappropriate activity in bank accounts Signatures on checks that differ from the elders Recent changes in will or power of attorney when elder is not capable of making those decisions Missing valuable belongings that are no just misplaced Lack of television, clothes, or personal items that are easily affordable Unusual concern by the caregiver over the expense of the elders treatment when it is not the caregivers money being spent

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by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN

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Neglect indicators Dirt, fecal or urine smell, or other health hazards in the elders living environment Rashes, sores, or lice on the elder Elder has an untreated medical condition is malnourished or dehydrated not related to a known illness Inadequate clothing Indicators of self-neglect Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills Inability to manage activities of daily living such as personal care, shopping, housework Wandering, refusing needed medical attention , isolation, substance use Failure to keep needed medical appointments Confusion, memory loss, unresponsive Lack of toilet facilities, living quarters infested with animals or vermin Warning indicators from caregiver Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver Attitudes of indifference or anger toward the elder Blaming the elder for his or her illness or limitations Defensiveness Conflicting accounts of elders abilities, problems, and so forth Previous history of abuse or problems with alcohol or drugs.

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